View
687
Download
0
Category
Tags:
Preview:
DESCRIPTION
Citation preview
1
Jeffrey F. Driver, JDExecutive Vice President
Chief Risk Officer
Stanford University Medical Indemnity and Trust Insurance CompanyStanford University Medical Center
November 18, 2008
The Model Methodology Part IIISolutions and Implementation
The Model Methodology: Data Into Action
2
Capture vulnerabilities as they occur– Contemporaneous analysis of asserted malpractice cases
Put them into context – Integration of relevant denominator data and peer comparative data
Are you still vulnerable? – Assessment of present-tense risk through risk assessments, focus groups
Determine potential solutions – Continuous identification of relevant models, processes, education, and training programs that
address key risk areas
Implement, educate, train– Championship by high-level leadership to effect real change and to sustain it
Measure/Metrics– Measure the impact in the near term (with a predictive eye for the long term)
PEARL – Process for Early Assessment and Resolution of Loss
3
Process for the Early Assessment &Resolution of Loss(PEARL)
PEARL Process Flow
4
• clinical judgement—sel/mgmt med
• pt monitoring—med regimen
• commun among prov—pt cond
• pt/fam edu—risks of meds
• med error—dispensing
• incorrect drug administration
• supervision—house staff
• sel/mgmt therapy—labor & delivery
• sel/mgmt therapy—pregnancy
• supervision—nursing
• fail/delay obtain consult/ref
• commun among prov—pt cond
• fail/delay ordering dx test
• pt monitoring—physiological
RM Issues
Summary of Model Patient Safety Initiatives
DiagnosticDiagnostic SurgicalSurgical OBOB MedicationMedication TargetTarget
Decision Making Support in EHR
• Diagnostic guidelines• Diagnostic algorithms
Closed Loop Communication
• Results Manager • Referral Manager• Pt. access to results• Tickler files for test & referral follow- up
Incidental Findings Follow-up
• Communicating Critical Test Results
Models/Solutions
Team Training: Improve Communication (e.g.)• Improved Consent Process• Surgical Safety Checklist
• Briefings (e.g., OR, morning/ shift)
• Timeouts
• Use of Critical Language / SBAR
• Communication triggers, residents to attendingsBar Coding /RFID • Retained FBsSimulation (e.g.) • FLS: Fundamentals of Laparascopic Surgery
▪ Team Training
▪ In-Situ Emergency Recognition training
Informed Consent Enhancement
▪ EMMI
Proactive Risk mAssessments
Team Training: Improve Communication (e.g.)• Briefings (e.g., OR, morning / shift)
• Use of Critical Language
EFM: Electronic Fetal Monitoring Education
▪ Existing education and APS
Decision Support (e.g., Obstetrical Care Guidelines) Embedded in EMR
Shoulder Dystocia Drills
Simulation (e.g.) • Shoulder Dystocia• Crisis response• Team Training
Proactive Risk Assessments▪ Labor and Delivery▪ Nurseries
Informed Consent Enhancement• EMMI
Medication Reconciliation (at all transition points)
▪Yes at SUMC
Improve Ordering Process (e.g.)
• CPOE: computerized physician order entry• E-Prescribing
Bar Coding
▪ Yes at SUMC
Improve Documentation• EMAR: electronic medication administration record
SHC Medication Administration “quiet time”
• misinterp of dx studies
• patient did not receive result
• commun among prov—pt cond
• fail to est differential dx
• fail in f/u sys—new finding
• lack/inad—history & physical
• result not recv'd by clin—oth
• results filed b/f clin review
• supervision—hosue staff
• commun among prov—pt cond
• poss tech prob
• fail to respond—pts concerns
• fail/delay order dx test
• misinterp of dx studies
• inadequate cons for surg proc
• fail to ensure patient safety
• policy/protocol not followed
• pt monitoring—physiological
• improperly utilized equip
• fail to respond—pts concerns
• staff training/education
• insuf/lack doc—clin findings
• pt monitoring—med regimen
Summary of Model Patient Safety Initiatives
NursingNursing EDED ResidentsResidents RadiologyRadiologyTargetTarget
• lack/inad asses—premature d/c
• fail to est differential dx
• access/scheduling/waiting
• supervision— house staff
• fail to read medical record
• insuf/lack doc—clin findings
• sel/mgmt therapy—medical
RM Issues
Models/Solutions
Team Training: Improve Communication (e.g.)• Briefings (e.g., OR, morning / shift)• SBAR (or other agreed upon tool)• Dashboard• Use of Critical Language
Simulation Training: Crisis Response, Cognitive, Technical skills
▪ Yes at SUMC
Organizational Policy re: Inpatient Boarders
Improve Communication (e.g.)
• Briefings (e.g., OR, morning / shift)• Use of Critical Language• Triggers (e.g., surgical care guidelines)
Fall Prevention Protocols
▪ Safe Patient Handling Programs
Infection Control Protocols (e.g.)
• Wound Care Team
Improve Communication (e.g.)
• Briefings (e.g., OR, morning / shift)• Care Guidelines (triggers when to notify supervising attending)• SBAR for handoffs
Team Training
Simulation Training▪ All surgical residents get Simulation Training and new interns now receive patient safety training via simulation
Communication of Test Results per ACR Guidelines• Preliminary reports • Failsafe procedures• Documentation (e.g., clarity of report, re: communication of results)
Triggers embedded in EMR (e.g., allergies, medications, health history)
▪ Yes at SUMC
Double Reads (e.g., audits)
▪ Yes at SUMC
Tickler System for Ensuring Follow-up
The Model Methodology: Data Into Action
7
Engagement in High Risk Areas – RMF Data – Fully-coded SHC Cases by responsible service
0
20
40
60
80
100
120
nu
mb
er
of
case
s
Claim Count
N=270 fully-coded SHC PL cases asserted 1/1/03-5/7/08.*Other includes Pathology, Allied Health, and Pharmacy.Total Incurred=aggregate of expenses, reserves, and payments on open and closed cases.Surgery=General Surgery, Orthopedics, Neurosurgery, Bariatric Surgery, Colorectal Surgery, Cardiac Surgery, Otorhinolaryngology (with Plastic), Hand Surgery, Ophthalmology, Otolaryngology (No plastic), Plastic (NOC), Pediatric Surgery, Oncology (Surgical), Thoracic Surgery, Urology Surgery, Vascular Surgery, Transplant, Podiatry.Medicine Subspecialty=Cardiology, Dermatology, Endocrinology, Gastroenterology, Genetics, Geriatrics, Hematology, Hospitalist, Immunology and Allergy, Infectious Disease, Oncology (Medical), Nephrology, Neurology, Physical Medicine/Rehabilitation, Pulmonary Disease, Rheumatology.
Perioperative Services Review Based on Claims Data
• Surgical Specialties are inherently high risk
• Besides RMF coded data, a number of unusual events within perioperative services
• Led to engagement of an outside consultant to assist SUMC with a full scale peri-operative services risk assessment (% day review, 4 consultants)
Results• 85 page report from the consultants outlining both best practices
and areas that could be improved
• Report also listed recommendations from the consultants as well as evidence based solutions
• 55 page action plan developed by internal experts
– Policies re-written
– Recommended improvements put in place by Medical Leadership and Nursing Leadership
– Partnership between Risk Management and Quality Improvement and Patient Safety Departments for action planning and implementation
Other Action Items from Deep Coded Data
• Simulation programs funded by SUMIT to address areas of vulnerability
• APS education to be offered to physicians in the next few months
• PEARL process implemented to assist physicians with disclosure of unanticipated and adverse outcomes, to learn from preventable outcomes on a real-time basis, and to compensate patients for injuries
• EMMI programs available for physicians to enhance the informed consent process and patient education– One early success story (ENT case)
Questions?
Thank you!!!
Recommended