Transcript University of North Dakota

Risk Management:
Best Practices to Optimize Prevention
All-Grantee Meeting, Washington D.C.
June 24, 2008
Petra S. Berger PhD RN, CPHRM
Healthcare Quality, Risk & Patient Safety Consultant
[email protected] - Phone: 517–281-7816
Learning objectives
• Discuss concepts and tools of risk
management, patient safety and
integration with quality improvement
• Describe ten clinical risk factors
(process & outcome) common @ Health
Centers, along with strategies of risk
prevention & control
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VITAL BRIDGE OVER TROUBLED WATERS
QUALITY MANAGEMENT
Patient Safety = Q. I.
Risk Management
= identify risk – respond – prevent
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DIVERSE QUALITY & RISK GOALS
on O N E Platform
• Efficiency & Cost control
• Access to care; Referral mgt
• Patient Satisfaction
• Clinical Effectiveness
• Regulatory compliance
• Patient Safety vs. error, delay, omission
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PURPOSE x 3: RISK MANAGEMENT
• STOP & PREVENT HARM
= Patient Advocacy
• PROTECT the Healthcare facility from
– litigation and financial loss
– patient and community distrust
• PROTECT involved Providers & Staff
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Health Center Trends and Issues
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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%
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Liability Analysis: 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 defendant failed to exercise
‘reasonable’ care, and adherence to
established clinical standards (expert testimony)
Injury proximately CAUSED by breach (foreseeable)
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Case Example: Medication Monitoring
• 58-year-old male patient is scheduled for a
major diagnostic procedure at the hospital
where a certified registered nurse anesthetist
(CRNA) provides conscious sedation.
• A required copy of the clinic medical record
is sent preoperatively. No mention is made
of the patient’s seizure medication.
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Case Example: Medication Monitoring
• 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
• The 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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Liability Analysis
Duty? Breach? Injury? Damages?
A. Standard of Care - prelude to Q. measures
Monitoring patient medication & document
Test result reported to & signed off by provider
Patient notified & documented
Treatment plan updated, w/ or w/out change
Medical records accurate & comprehensive
B. CRNA & hospital standards of care
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PRIMARY STRATEGY OF RISK CONTROL
Risk Identification & Analysis
• Event or Claims review: Root Cause analysis
• Incident reporting - adverse event (1 - 30%)
– Omitted or delayed diagnostic workup
– Adverse medication event
– Patient or family complaint or feedback
– Staff feedback & surveys
– ‘Risk reporting marathons’ = snapshots
• Occurrence Screens
– Missed appointments; Waiting times
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Risk process #1: Patient communication
• Patient assessment & interview
• Treatment planning & Goal contracting
– Non compliance – Termination of care
• Informed Consent / refusal
• Health instruction – literacy – interpreters
– Explain back / read back
• Patient feedback & complaints
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Informed Consent – or refusal
• Used whenever an invasive procedure is
proposed that carries a risk of harm
• Medical Provider has 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
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Complaints & Regulatory requirements
• CMS CoP - Infraction of patient rights IF
– Evidence of non responsiveness
– Non-resolution of complaint or grievance
• Complaint = verbal, informal, promptly resolved
• Grievance = req. investigation; 7d TAT; appeal
• Develop P&P w/ time frame & implement
• Inform patients on how to report a concern
– Use grievance committee as needed
‘Pt Complaints & Grievances–No Leeway for Lapses in Resolution’ RMPSI IE
08/13/07
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Complaints: Preventive factors
• Organizational Factors
– Culture of Patient centeredness
– Certain care processes that invite complaint
• Medical Provider & Staff Factors
– Communication skills; Clinical skills
– Time pressure, fatigue, frustration
• Patient Factors
– Difficulty understanding; feeling abandoned
– Stress of diagnosis, finance, grief, fear
– Somatizing; non adherence
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Disclosure – What and How
• Known Facts – s/p investigation
–
–
–
–
Same as documentation, medical record
SUMMARY: Sequence of events
SUMMARY: Discovered Cause(s) per evidence
Clinical results & effects on patient
• “Corrective actions taken” – no staff names
• Empathy & concern expressed to patient
• Apology if error made and harm caused
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Risk Process #2:
Organizational & Provider Communication
• Flow & Availability of Organizational
Information (P & P, Staff Educ., Pt. Info., MR)
• Inter-provider team relations; conflict mgmt
• Communication breakdowns occur during
hand-off at transition points from one
provider to another -- verbal & written
• Communication barriers are cause of 2/3 of
serious medical errors (JC reports)
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Risk process #3:
Litigation review of
MEDICAL RECORD DOCUMENTATION
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•
•
•
•
•
•
•
?Treatment rationale; ?Diagnostic Follow Up
Omissions \ delays in needed care
Contradictions; confusion between provider
Finger pointing; subjective statements
Corrections: Write overs & White out
Illegibility & error prone abbreviations
Altered Medical Records; “Late entries”
Do not mention ‘incident report completed’
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Risk process #4:
Clinic Operations
(systems)
• Continuum of care (62% claims) & F. U.
– vs. Fragmentation across settings
– Referral management
• Diagnostic test tracking
• After hours coverage & Telephone triage
• Access to care & No shows
•
Missed Appointments:
– Tickler system, patient return for annual
exams, FU tests, preventive screens
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Risk process #5:
Clinical Practice
• Medical evaluation & Treatment
– Complex medical conditions: Cancer, Co-morb.
– Medication therapy; Pre-natal risk factors
– Pre- and post-surgical patient evaluation
• Use of Practice Guidelines: decr. variability
– Asthma, Anticoagulants, Stroke, Pediatric Fever
• Guarding against Complications (preventable)
– OB, Surgical procedures, Emergency
Sample protocols can be accessed at http://www.guideline.gov/
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Risk Outcome # 6:
Diagnostic Error, Delay, Oversight
Most frequent
 Cancer – Myocardial infarction – Stroke –
Meningitis – Acute abdomen – Fractures –
Prenatal risk factors – Infections post surgical
Factors
• Atypical signs & symptoms
• Incomplete or inaccurate information about
medical history; many co-morbidities
• Insufficient diagnostic work up; Delays
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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
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Diagnostic Test tracking
per Flowchart & Checklist
– Test ordered by med. provider & log
– Request form created - copy retained
– Test completed - patient compliance?
– Results received and logged in / ck log
– Results reported to provider (same day
for abnormal /critical value results)
– Patient notification documented
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Risk process # 7:
Medication Safety
Adverse Medication events related to phases:
 Product labeling, packaging, nomenclature
 Prescribing: Indications, interaction, off label
– Antibiotics, anticoagulants, narcotics,
cardiovascular, steroids
 Dispensing: compounding, distribution error
 Administration: wrong drug/ dose/ route
Source: National Coordinating Council on Medication Error Reporting and
Prevention –www.nccmerp.org
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Risk process #8:
EQUIPMENT – EOC – EMERGENCY RESPONSE
Emergency protocols implemented and monitored for
• Medical emergency
• 1 BLS trained staff on-site at all times
• Crash cart (incl. pediatrics) & checks
• Behavioral emergency
• Building /weather (power outage; fire)
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Behavioral Emergencies
• OSHA cites healthcare facilities under general
duty clause for failure to prevent patient
violence against healthcare workers
• Medical providers & staff exposed to potentially
dangerous confrontations incl. ill-intended
trespassers
• Security audits needed to reveal problems
• Address potential risk of violence
Source: ECRI, HRC Risk Analysis – Overview: Managing Risks in Physician Practices, July
2003.
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EQUIPMENT LIABILITY
Monitoring to protect against risk
• 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
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Environment of Care
Infection control & Hazardous Material
• Develop, implement & monitor an Infection
control (I.C.) plan pertinent to pt population
• Involve I.C. professional
• Protect staff, providers, patients, and
visitors from hazardous material – BBP
• Trend I.C. events & take corrective action
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Risk process #9: Clinic
Staff performance
• Staff qualification & orientation
– Qualified staff
– Clear, written directives
– Job-tailored Training, initial & ongoing
– Human factor remedies: distraction,
memory overload, fatigue, confirmation bias
– Performance feedback (data based)
– Staffing levels & Material resources
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Accountability & Just Culture
• Imperfect behaviors, lapses, oversight
– Inadequate realization of risk, inadequate
diligence – systems barriers & gaps?
• At-risk behaviors -- e.g. shortcuts
– Intentional conduct that unintentionally
increases risk: non compliance: double check
• Reckless behavior
– Recognition of high risk but risk is disregarded
– Intentionally hazardous acts
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Credentialing Focus
Initial vs. Re-credentialing
• INITIAL:
Licensure verification, References re: privileges
Qualifying education & experience, NPDB ck
Provisional credentialing and Proctoring
• RE-CREDENTIALING: need Quality & Risk data
– Which measures to select & how to obtain
– What to do with quality & risk information
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Risk process #10: Provider performance, MS
• Quality measures = trending
• Service Volume – Guideline adherence
• Documentation – Prescription review
• Peer Review = Risk events
• Adverse outcomes; Inadequate processes
• Complaints; Disruptive behavior
• Proctoring & Provisional Credentialing
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Credentialing Files: Risk & Quality section
• Credentialing files organized into 2 sections
• Top Confidential, keep secured
• Separate Quality file per practitioner
– Sect. A - Quality data trends
Guideline adherence; MR Documentation
– Sect. B - Risk data: events & practice pattern
P.C.E. = Potentially compensable event
Pt. c/o; RCA results; Peer review reports
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Medical Record “Pertinence” Review
• Adequate health history & physical exam as
pertinent to pt. presentation & complaint
• Clinical risk factors ID’d on Tx plan
• Conclusions & Dx supported by findings
• Diagnostic & therapeutic orders supported
• Patient /family involved in Tx plan
• Progress notes indicate continuity of care
• Consulting providers support Tx plan
• Abnormal findings addressed
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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
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External Peer Review
• Purpose
– Baseline data \proctor role \SE case review
• Contract w/ external qualified physician
– Designate external MD as official member of peer
review committee of requesting facility
– A contract protects MD reviewer under HCQIA
– MD reviewer stays anonymous & unidentified
– MD may clarify questions re: findings, BUT:
– External reviewer is adjunct to internal peer
review decision; NOT involved w/ investigation
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