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CREATING RESPECTFUL CARE TEAMSCLINICIAN BEHAVIOR AND PATIENT SAFETY
page 14
DESIGNING GOOD FOLLOW-UPTHE HEALTH CARE LEADER’S ROLE
page 4
FROM VISION TO REALITYDESIGNATING EXECUTIVE SPONSORS
FOR INITIATIVESpage 12
A NEW AGE FOR SENIOR CAREONE LEADER’S JOURNEY
page 18
LEADING IN HEALTH
CARE
Good for care teams. Good for business.Spring 2019
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LEADING IN HEALTH
CARE
CREATING RESPECTFUL CARE TEAMSCLINICIAN BEHAVIOR AND PATIENT SAFETY
page 14
DESIGNING GOOD FOLLOW-UPTHE HEALTH CARE LEADER’S ROLE
page 4
FROM VISION TO REALITYDESIGNATING EXECUTIVE SPONSORS
FOR INITIATIVESpage 12
A NEW AGE FOR SENIOR CAREONE LEADER’S JOURNEY
page 18
Good for care teams. Good for business.Spring 2019
We wanted to find new ways to do more for those who already do so much. So we created Constellation. Working together with liability insurance companies, we offer products and services beyond insurance that help reduce risk, streamline care, even lessen caregiver burnout and turnover. Because at the end of a long day, good care is good business. See how working together can benefit you at ConstellationMutual.com
© 2019 Constellation
Together for:
We’ve changed our name! Brink® magazine is now Common Factors™, a better reflection of our goal to bring our readers data, insights and ideas—the common factors that come together to help you create healthy care teams and a healthy bottom line.
©2019 Constellation. All rights reserved. Reproduction in whole or in part without permission is prohibited. Common Factors™ is a trademark of Constellation
Common Factors™ is published two times annually by Constellation, a growing portfolio of medical professional liability insurance and “beyond insurance” companies formed in response to the ever‑changing realities of health care and dedicated to reducing risk and supporting physi‑cians and care teams, thereby improving business results. Formed in 2012 as a response to an increasingly challenging market, Constellation is guided by its own board of directors comprised of physicians, medical liability professionals and health care leaders. MMIC is a founding member company; UMIA joined Constellation in 2013 and Arkansas Mutual joined in 2015.
To download Common Factors, visit ConstellationMutual.comTo contact the editor, please send an email to Liz.Lacey‑[email protected]
In an interview a few years ago, Donald Berwick, MD, MPP, president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI), noted that one of the lessons we’ve “learned and relearned and relearned” in health care is that, while all of us can improve our individual games,
“To improve health care—this interdependent system—let alone health itself … only leaders can set in place the context, the support, the encour‑agement, the insistence, the vision, the regular attendance that allows improvement in complex systems to occur.”
Today, we continue to learn and relearn that lesson. In this issue of Common Factors™, which is focused on leadership in health care, we see just what that interdependence entails. We see how, if a physician at the top of their game makes exactly the right diagnosis—but that diagnosis is not communicated to the patient in a timely manner—it counts as a diagnostic error, and one that can have disastrous consequences, as our claim data can attest.
Health care leaders have a critical role to play in creating safe environments in their organizations.
Making sure your organization’s follow‑up systems are in place and operating properly is one of the best ways to ensure that information vital to your patients’ care and health doesn’t fall through the cracks. You’ll find valuable ideas on re‑engi‑neering faulty systems in the following pages.
Creating a culture of respect and civility—where everyone feels safe advocating for the best care for patients—is another area that requires strong leadership and active support. For one health system in Minnesota, it meant shutting down the operating room for a day (except for emergencies) to make sure everyone was hearing the same pro‑civility message.
Senior living communities face their own chal‑lenges in providing consistently high levels of care, including a burgeoning population of those in need of services, scarcity of staff and low reimbursement rates. You’ll see how the leader of one senior living organization is blending the best of a “hospitality model” and a “medical model” to serve the needs of residents across a larger and larger continuum of care.
Sometimes, the most effective way to advance initiatives is through joint leadership. Another organization assigns both an executive sponsor and a clinical sponsor to every initiative to ensure that multiple perspectives are represented and that the solutions that result work for all parties.
An enterprise as complex and interdependent as health care requires consistent leadership and con‑stant collaboration. We won’t make the necessary progress by focusing only on our own game. I think it’s good to keep in mind the title of a presentation Dr. Berwick delivered at a recent IHI National Forum on Quality Improvement in Health Care: “Together or not at all.”
Working with you, together for the common good, is a continuous honor.
Bill McDonoughPresident and CEO, Constellation
Common Factors / Spring 2019 / 1
DEPARTMENTS
4
12
14
18
2NOTABLE
Spring 2019
21BOOK REVIEW
Connecting with Self and Others Through EmpathyAn exploration of “The Empathy Effect” by Helen Riess, MD.
22CLAIM REVIEW
Follow-up System Failure Leads to Missed DiagnosisA patient and her primary care physician do not receive communication about an abnormal mammogram.
24CLAIM REVIEW
Communication Chaos at Transition of CareAn elderly diabetic patient with dementia is transferred from a hospital to a memory care unit with orders for duplicative doses of diabetes medication.
28MEDITATIONS ON MEDICINE
Elephant in the Room Courageous leaders need to stand up to incivility in the health care workplace.
FEATURE SECTION:
LEADING IN HEALTH CARE4DESIGNING GOOD FOLLOW-UPA new lens on diagnostic error magnifies the leader’s role in creating follow‑up systems that work.
12FROM VISION TO REALITYDiligent leadership moves the needle on continuous quality improvement.
14CREATING RESPECTFUL CARE TEAMSDisrespectful clinician behavior negatively impacts patient care and the bottom line.
18A NEW AGE FOR SENIOR CAREOne leader shares his journey through relentless change.
HOT TOPIC:
26ARE YOUR OPIOID PAIN MANAGEMENT PRACTICES CURRENT?Technology and a team‑based approach can increase patient safety and reduce risk.
Common Factors / Spring 2019 / 1
NotableNEW APP RISK REPORT HIGHLIGHTS RISK FACTORS FROM CLAIM DATA
From deep‑dive analyses of claim alle‑gations, Constellation’s data analytics team has created risk reports that can help identify common underlying fac‑tors organizations can use to proactively manage risk and help prevent patient or resident injury. The Advanced Practice Provider (APP) Risk Report is newly avail‑able on MMICgroup.com or UMIA.com > Risk Management > Bundled Solutions > Patient‑Centered care > Teamwork.
The following reports are also avail‑able by accessing MMICgroup.com or UMIA.com > Risk Management > Bun‑dled Solutions: / Preventing Diagnostic Error Risk Report
/ Long‑Term Care Risk Report / Hospital Risk Report
Our risk and patient safety experts can work individually with policyholders to help apply the risk reports’ data‑driven insights by outlining a unique action plan for organizations.
LEARN ABOUT RISK IDENTIFICATION AND PATIENT
SAFETY SOLUTIONS BY CONTACTING PATIENT.SAFETY@
MMICGROUP.COM OR [email protected]
LOOKING INTO ALTERNATIVE RISK FINANCING?
Whether you’re looking to take on more risk or are transitioning out of a self‑insured program, we’re here to help. As health care systems grow and con‑solidate and governmental regulations change with little warning, Constella‑tion’s medical professional liability insur‑ance companies are skilled in helping customers manage their risk.
Our alternative risk financing options can provide tailored insurance programs with strong financial backing and ben‑efits based on a health system’s unique needs, and include: / Self‑insured retentions / Fronting arrangements / Loss portfolio transfers / Large or small deductibles / Stand‑alone reporting endorsements
FOR MORE INFORMATION, CONTACT DANA D’ARRIGO AT DANA.D’[email protected]
NEW PES MODULE HELPS CUSTOMERS NEGOTIATE BETTER RATES
The Physician Empowerment™ Suite (PES) now includes a new Reimbursement Effectiveness module, released Summer 2018, that enables practices to develop a “value story” quality report that can be used during payer negotiations to maxi‑mize reimbursement. The module devel‑ops an analysis of payment rates for a practice’s top commercial payers, help‑ing to identify which services are under‑paid to justify increased fee‑for‑service and fee‑for‑value reimbursement rates during payer negotiations.
Developed by SE Healthcare™, PES is an online platform with multiple mod‑ules designed to produce credible and actionable feedback to improve oper‑ational performance and effectiveness, reducing risk, enhancing economics and delivering better patient experience.
CONTACT [email protected] FOR MORE INFORMATION.
2 / Common Factors / Spring 2019
Spring 2019
Visit our new website at ConstellationMutual.comGet an overview of our broad coverage options that go beyond medical professional liability (MPL) insurance, learn about our rich history, and get the details on our portfolio of new prod‑ucts and services for our customers. And, meet our leaders who
care deeply about ensuring that Constellation can best serve our physicians, clinicians and health care organizations well into the future—so they in turn can provide excellent care to their patients while building a healthy business and healthy teams.
FOLLOW CONSTELLATION ON SOCIAL MEDIA!
We share educational webinars, quick links to relevant and timely resources, plus articles from Common Factors™, health care tips and tools, and much more. We also post educational webinars on our YouTube channel.
Like, Subscribe, and Follow to stay up‑to‑date and in‑the‑know on trending health care topics that impact you, your practice and your organization.Twitter @Together_4_GoodLinkedIn at Constellation, Together for
the Common Good.Constellation YouTube channel,
Constellation, Together for the Common Good.
Together for:
Every day you’re reminded why it’s so important to work together to improve care. But hurdles arise, competition grows, regulations increase. What if your insurance company could help? Working together with Constellation, it can. Constellation offers solutions that reduce risk, support care teams and improve the bottom line. See how working together can benefit you at ConstellationMutual.com
© 2019 Constellation
ConstellationMutual.com Table of Contents2 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 3
Designing Good Follow-upA new lens on diagnostic error magnifies the leader’s role
in creating follow‑up systems that work.
By Lori Atkinson, RN, BSN, CPHRM, CPPS, Trish Lugtu, MS, CPHIMS,
and Anne Geske
4 / Common Factors / Spring 2019
A 54‑year‑old woman involved in a car accident presented to her local emergency department (ED) with complaints of left arm and shoulder pain. The ED physician examined her, ordered X‑rays—which he read as negative—and diag‑nosed a soft tissue injury and shoulder strain. He sent the woman home with instructions to apply cold compresses, use over‑the‑counter medica‑tion for pain and follow up with her family phy‑sician if she experienced further shoulder problems.
A year later, the woman went to her family physician for a cough that would not go away. The phy‑sician ordered a chest X‑ray, and the radiologist noted in his report a left upper lung mass with medi‑astinal adenopathy. The radiol‑ogist compared this X‑ray with the one done the previous year during her ED visit and noticed the previous radiologist identified an incidental finding of a density
in the upper left lung and documented this in his over‑read report. The family physician referred the woman to a specialist who diagnosed lung cancer. She underwent chemotherapy and radi‑ation treatment but died six months later. The woman’s family sued for malpractice.
In reviewing the malpractice claim filed by the woman’s family, medical experts criticized the hospital for having no system to follow up on
tests and images ordered in the ED. All X‑rays read by ED physi‑cians were routinely over‑read by radiologists, but the hospital had no process for reviewing the over‑reads, noting discrepancies and contacting primary care phy‑sicians and patients for further care. During the investigation of this adverse outcome, the hospi‑tal risk manager also discovered the ED had no process for follow‑ing up on patients who were dis‑charged with pending test results.
55% of outpatient cases with a diagnostic-related allegation involve a follow-up
system failure
4 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 5
Follow-up systems and dataThe right systems and processes could have prevented the woman’s lung cancer from remaining undiagnosed for a full year. We call these kinds of systems and processes “follow‑up systems.” The National Academies of Sciences, Engineering and Medicine say that diagnostic error isn’t simply failing to correctly diagnose, it’s also the failure to establish an accurate and timely explanation of the patient’s health problem or the failure to communicate the problem to the patient.1
This bears repeating: Not communicating a diagnosis to a patient in a timely manner is a diagnostic error—the type of diagnostic error that happens when follow‑up systems don’t exist or are simply poorly designed.
Follow‑up system failures are where breakdowns in com‑munication and patient care coordination are captured in our claims analysis. A review of Constellation claims found that 57 percent of all diagnostic‑error cases occurred in the outpatient setting, and of these cases, 55 percent involved breakdowns in follow‑up and care coordination (see CRICO’s 12‑step diagnostic framework). Our review strikingly revealed that even when appropriate clinical steps were taken to lead to a correct diagnosis, errors in diagnosis still occurred due to follow‑up system failures.
This insight—that these outpatient diagnostic‑error cases are as much about systems and processes as they are about clinical judgment—breaks traditional thinking that an accurate and timely diagnosis is the responsibility of the physician alone. Injuries caused by these types of errors are tragic because they’re preventable with the implementation of reliable processes, policies and education. In turn, claims due to such injuries are costly to organizations and difficult to defend because they’re preventable.
These system inefficiencies and failures are the very things CEOs, administrators and clinician leaders have a direct ability to influence: people, processes and technology. This is good news, because by looking at diagnostic error through the lens of communication and process failures, we see clearly that lead‑ers play a part. They can ensure that the workflow processes and documentation systems their care teams use to coordinate care and communicate with each other and with patients are working well.
What drives follow-up system failures?Simply put, inefficient, error‑prone processes drive follow‑up system failures. System inefficiencies and failures cause diag‑nostic errors in several specific ways. When teams don’t utilize team‑based care and reliable systems, inefficient workflows and diagnostic errors result. Here are some examples of inefficiencies and wasteful work:
/ Clerical overload. The AMA estimates that physicians spend nearly two hours on EHR deskwork for every hour of clinical face time with patients,2 but many organizations don’t use a team‑based care model to handle these increasing loads. The highest‑trained clinicians should be relieved of performing clerical functions by using team‑based work‑load redistribution.
/ EHR functions not optimized. Studies show that when EHR use isn’t optimized, 25 percent of outpatient providers don’t have a method to confirm that all ordered tests have been completed, with 73 percent not using EHR technologies to their full capability.3
/ Referral follow-up failure. In one study, 25 to 50 percent of referring physicians didn’t know if their patients saw the specialist after referral.4 A closed‑loop referral process and delegation of monitoring to a member of the care team can solve this problem.
/ Discharge summary gaps. Researchers found that 70 percent of patients had at least one pending study when discharged from the hospital, but only 18 percent of these were communicated in the discharge summary.5
/ Incidental finding follow-up failure. One study of ED patients found that 56.3 percent of abdominal scans had at least one incidental finding, but only 9.8 percent were disclosed in discharge paperwork. In addition, only 40.9 per‑cent of life‑threatening findings had documented follow‑up.6
Leading follow-up system initiativesThe stakes are high when follow‑up systems failures occur—not only for patients, but also for the health care organization’s bottom line. Just some of the costs include:
/ Accreditation loss—many accrediting standards relate to follow‑up systems
/ Financial loss or penalties because of the following: / Poor patient experience scores / Hospitalizations and readmissions / Unnecessary or duplicate lab tests / Poor outcomes impacting value‑based care metrics / Inefficient workflows, especially related to EHR tasks / Turnover due to workload burnout / Recruitment costs to replace a physician
/ Reputation damage / Malpractice claim losses
Because the cost of derailed diagnosis is so high, having designated executive and operational sponsors is key to doing this important, ongoing work. Executive and clinician leaders must champion initiatives to ferret out the gaps in their follow‑up systems, as well as gaps in patient care handoffs to other clinicians or health care organizations.
These system inefficiencies and failures are the very things CEOs,
administrators and clinician leaders have
a direct ability to influence: people, processes
and technology.6 / Common Factors / Spring 2019
Following up with patientsRegarding following up with patients, clinicians and team members must ask these questions:
/ How do we communicate test results to patients?
/ How do we proactively communicate with patients about test results so they know that no news is NOT good news?
/ How do we audit communication systems to ensure patients and other clinicians involved in the patient’s diagnosis and treatment receive test results?
Initial diagnostic assessment1. Problem noted, care sought: 1% of cases2. History and physical conducted: 17%3. Patient assessed and symptoms evaluated: 34%4. Differential diagnosis established: 30%5. Diagnostic tests ordered: 30%
Tests and results processing6. Tests performed: 5% of cases7. Tests interpreted: 25%8. Test results transmitted to/received
by ordering clinician: 5%
Follow-up and coordination9. Clinician follows up with patient: 29% of cases
Issues: Findings are not communicated to the patient, follow‑up testing is not arranged or follow‑up is not documented.
10. Referrals/consults: 13% of cases Issues: Appropriate referrals to specialists (or consults) are not made or adequately managed, or identification of the clinician responsible for ongoing care is unclear.
11. Patient information communicated among care team: 23% of cases Issues: One or more providers fails to fully review or share patient information that influences ongoing diagnostic process.
12. Patient and providers establish follow‑up plan: 12% of cases Issues: The patient fails to adhere to the follow‑up plan, including appointments and the treatment regimen.
CRICO’s 12-step diagnostic frameworkWhere follow-up systems fit in
Constellation partners with Harvard‑based CRICO Strategies to classify the underlying issues in our malpractice claims in a standardized way. Using CRICO’s 12‑Step Diagnostic Process of Care Framework, Constellation mapped clinical and oper‑ational breakdowns along the diagnostic process. The data
pointed to gaps in the care team’s communication process (steps 9–12), revealing that even when providers take the appropriate clinical steps to arrive at a diagnosis, operational failures may still lead to diagnostic errors.
MMIC N=230 MPL diagnosis‑related outpatient claims asserted 2013–2017 as of 12/31/2018
6 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 7
The importance of reducing diagnostic error by addressing follow‑up system failures cannot be overstated. Improving follow‑up systems reduces risk, increases team productivity and affects an organization’s reputation and bottom line by bettering patient experience and incurring fewer malpractice claims. It’s a win‑win‑win—good for patients, care teams and business.
Improving the diagnostic process takes leadership support, teamwork and collaboration. We recommend involving the entire team—including health information technology (HIT)—using the following three steps.
1. Re-engineer processesFollow‑up system revision needs to start by re‑engineering failure‑prone, inefficient processes using proven performance improvement methods such as the following:
/ Process mapping models a process step by step and includes roles and accountabilities.
/ Failure modes and effects analysis (FMEA) is a proactive method for evaluating the steps in a process to identify where and how it might fail.
/ Plan, do, study, act (PDSA) is a cyclical process to do a small test of a change before spreading the new process through‑out an organization.
/ Root cause analysis is a reactive process done after an adverse event to identify causal and contributing factors to the event.
/ Automated audits of medical records and logs indicate if a process really works.
/ Safety scorecards track performance over time.
Mapping processes and rolesCapturing processes collaboratively and including every role on the performance improvement team are important, as each role knows only a part of the whole story. Because the EHR is central to the operation of health care, bringing HIT to the table at the beginning of a redesign process, as well as all the way through—from implementation to evaluation—is essential.
When process mapping, take team‑based care into account. Team‑based care is a strategic redistribution of work among members of a practice team in which the physician or advanced practice provider and a team of nurses and/or medical assis‑tants share responsibilities for patient care. In this model, all members of a clinician‑led team play an integral role in provid‑ing patient care.7 Not all steps in the follow‑up process need to be handled by the clinician. Identify the steps that can be safely and effectively handled by others on the team, then delegate them to team members using their highest level of training and scope of practice (see Implementing team‑based care sidebar).
Next, adjust the workflow to capture all the variations in your processes. Ask the following questions:
/ What happens to the workflow when you have paper orders versus electronic orders?
/ What about variations in the patient notification process? / What happens when there is an amended or revised report?After mapping out the process—including variations—
model the process using “swim lanes” to identify roles and responsibilities. Each swim lane represents the role and respon‑sibility for that step in the process. You can then evaluate each step of the process using FMEA and re‑engineer the process to make it safer and more efficient.
Improving follow-up systems
8 / Common Factors / Spring 2019
Implementing team-based care: Starting points
Team‑based care spreads the diagnostic‑process load among the team. The following tasks are the most critical places to start for reducing errors and increas‑ing productivity:
/ In‑basket management for normal‑test‑result review and patient communication
/ Pre‑visit planning, including ordering tests (CPOE) / Expanded rooming, including test‑result reconciling / Post‑visit referral management and follow‑up / Telephone and portal symptom management via
written protocols / Final reads and incidental finding follow‑up / Tests pending after discharge follow‑up / Team documentation
1 Write down the name of the process at the top.
2 Ask the team, “What happens first in the process?” and write it down on the far left, in that role’s “swim lane.”
3 Draw a box around it.
4 Ask the team what usually happens next in the process; write it down below or to the right of first box; draw a box around it.
5 Draw an arrow linking the two boxes.
6 Ask the team if there are alternative ways to achieve the next step in the process.
7 Keep going, asking the team, “What happens next?”
8 Review the map and revise.
Lab Testing Process —ordering through notification
Pro
vid
ers
MA
sLa
bo
rato
ry
Source: AHRQ.gov
Lab reconciles specimen with order
EHR transmits order to laboratory
MA types order into EHR
Provider decides to order lab test(s)
2
3
Provider types order directly into EHR
4
5 7
Provider writes order on billing sheet;
hands to MA 6
1
Process mapping step by step
8 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 9
Prioritize initiatives with FMEAReturning to the car accident in the example of the 54‑year‑old woman, a place to start would be to use FMEA, asking the following questions:
/ What are the steps in the process to review and communi‑cate final reports and over‑reads?
/ When could the process fail? / What causes it to fail? / What happens when it fails? / How likely is it to fail? / How will we detect the failure? / How severe is the impact when a failure occurs? / What can we do to prevent the failure?The Institute for Healthcare Improvement has an excellent
FMEA template for evaluating the steps in a process to identify where and how the process might fail. The tool captures all these questions and their answers, then assigns a numerical value to the probability of failure and the severity of injury to the patient. The numerical values are multiplied to generate a risk profile number to help prioritize performance improvement initiatives. The tool also captures what can be done to prevent potential failures. Assemble your team and use your process map to perform an FMEA for each step in the process to evaluate the process for reliability.
Re-engineer, test, evaluateAfter your team completes an FMEA for each step, re‑engineer your process, inserting the necessary steps to reduce the chance and impact of failures. When you have re‑engineered the process, remap it, then test the new process to ensure it works without failure using small tests of change (PDSA). Roll the new process out with a small team, study the effects, change what isn’t working, then spread the new process to other teams.
2. Employ policies and toolsAfter re‑engineering, testing, and evaluating your processes, make them organizational policy. Outlining standard workflow processes in policies is an essential way to ensure everyone on the team understands “this is how we do things.”
Develop policies using the evidence‑based practices team members are expected to follow, including test management, result management, critical test results reporting, patient por‑tal communication, missed appointment tracking and referral management. Accountabilities for team‑based care should also be outlined in your policy, including indicating the specific roles and their responsibilities within the processes.
Employ process and communication tools that can be used to optimize your test‑management and communication processes. Diagnostic process tools include algorithms, care maps and standing order sets. Communication tools include IPASS, SBAR and team huddles.
How do you know if your re‑engineered processes are work‑ing and your policies are being followed? One way is by doing medical‑record audits that can indicate how your processes are working from efficiency and reliability standpoints. After your new procedures and policies have been implemented for a period of time, assess compliance by performing automated medical record and EHR report log audits. Then, enforce your policy standards, and be transparent about the consequences and outcomes when policies aren’t followed.
3. Engage, educate and support teams and patientsEducation is paramount to engaging clinicians and team members in understanding and improving the entire diagnostic process. Once you have re‑engineered processes and made them policy, education helps the care team understand “why we do it this way.”
Combined clinician and team member education should include the following elements:
/ A primer on the causes and contributing factors of diagnos‑tic error and how follow‑up systems support the diagnos‑tic process
/ A discussion of roles and accountabilities in the diagnostic and follow‑up systems processes
/ Training on how to work in a team‑based care model using proven communication tools, such as IPASS, SBAR and team huddlesUse diagnostic‑error storytelling (e.g., claim reviews are
available on MMICgroup.com and UMIA.com after logging in) to engage clinicians and care‑team members on their roles in preventing diagnostic errors. Integrate performance improve‑ment into team‑member roles. Frontline team members have the best view of how follow‑up systems fail and can bring direct knowledge of how to improve diagnostic and communica‑tion processes.
Patients and familiesOnce your processes have been re‑engineered and imple‑mented by the care team, bring in the patient and family as part of the diagnostic team. Patient engagement should incorporate health‑literacy tools such as Ask Me 3, teach‑back and empa‑thetic communication. Patient‑communication tools such as a Patient Visit Summary, Patient Testing Summary and Patient Referral Form (sample forms are available to policyholders after logging in to MMICgroup.com and UMIA.com) help patients become active members of the diagnostic team.
Remember, almost one‑third of claims involve follow‑up and coordination issues. Including patients as part of the team adds another layer of safety—if they don’t hear back about test results, patients can contact the care team.
10 / Common Factors / Spring 2019
Using the EHR to initiate or evaluate processes
EHRs, because they are filled with data, can empower organizations to automate medical record audits. Collaboration is key to figuring out what’s possible.
If we know the inputs into the EHR fields, we have the potential to create automated reports that can calculate the dates and times of those inputs. We can get lists of patients that are overdue for follow‑up appointments or have missed follow‑up appointments without rescheduling. We can uncover orders not completed and letter‑generation processes that failed. We can uncover broken orders or provider behaviors, such as a high percentage of signing off without review.
Using EHR audit reports is a good way to begin identifying unsafe processes, and they can be used at the beginning
of re‑engineering processes, as well as during the evaluation stage. In any case, including HIT throughout the process is critical. This takes collaboration. Ask your HIT team and your EHR vendor what can be pulled out of the EHR to evaluate follow‑up systems.
Over time, you can track your performance with the use of HIT safety scorecards. From an HIT and a risk‑man‑agement perspective, you can track the causes of diagnostic errors or near misses, answering questions such as:
/ Was it a vendor issue? / Was it an internal HIT issue? / Was it a process‑design issue? / Is training‑content improve‑
ment needed? / Is individual training needed? / Did HIT prevent a near miss?
LORI ATKINSON, RN, BSN, CPHRM, CPPS
Content Manager and Patient Safety Expert
Constellation
TRISH LUGTU, MS, CPHIMS
Senior Manager, Advanced Analytics
Constellation
ANNE GESKE
Managing Editor, Common Factors
References1. National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. bit.ly/2G59IiV Published September 2015. Accessed December 6, 2018.
2. Sinsky, CA, Basch P, Fogg JF. Electronic health record optimization: strategies for thriving. American Medical Association. bit.ly/2zNrDFh Published August 30, 2018. Accessed December 6, 2018.
3. Rumball‑Smith J, Shekelle P, Damberg CL. Electronic health record “super‑users” and “under‑users” in ambulatory care practices. J Manag Care. 2018;24(1):26‑31.
4. Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. The Milbank Q. 2011;89(1):39‑68.
5. Kantor MA, Evans KH, Shieh LJ. Pending studies at hospital discharge: a pre‑post analysis of an electronic medical record tool to improve communication at hospital discharge. J Gen Intern Med. 2015;30(3):312‑8.
6. Thompson RJ, Wojcik SM, Grant WD, Ko PY. Incidental findings on CT scans in the emergency department. Emerg Med Int. 2011;2011:624847.
7. Sinsky C, Rajcevich E. Implementing team‑based care: engage the entire team in caring for patients. American Medical Association. bit.ly/2E206D3 Published October 7, 2015. Accessed December 6, 2018.
ConstellationMutual.com Table of Contents10 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 11
From Vision
to RealityDiligent leadership moves the needle on continuous quality improvement.
By Anne Geske
12 / Common Factors / Spring 2019
Care teams look to their executive and clinician leaders to prioritize and execute the quality and patient safety culture initiatives of their organiza‑tions. Executive leaders, along with their clinicians, provide inspiration, accountability and resources. Without leadership to ensure staff have resources such as time, people, training and budget, import‑ant quality and safety work won’t get done.
In the arena of clinical initiatives, HealthPartners has developed a “best practice” collaborative model to promote success of the company’s initiatives. The model involves designating execu‑tive sponsors and clinical leaders for every quality initiative in every setting. “We don’t have a formal initiative in this organization that does not have an executive sponsor,” says Cara Hull, chief quality officer at HealthPartners. “Executive sponsors are a key and critical step in good quality work. We identify executive sponsors as well as operational sponsors. We even have training in our organization for the role of executive sponsor.”
HealthPartners, headquartered in Bloomington, MN, has grown over the years to offer health insurance in six states, encompassing 16 employers, 90‑plus clinics and hospitals with 55 specialty and primary care service lines, and seeing 1.2 million patients per year. One quality initiative currently in progress involves follow‑up systems around clinically significant incidental findings in test results, such as those in radiology or pathology.
“We identified an area of opportunity for improvement,” says Hull, “where if someone is getting a test for a specific reason but they find something else—an abnormal finding unrelated to why that test is being done—how do we flag that, track it and make sure there’s appropriate follow‑up? We want to make sure it gets to the right provider and track the chain of command of who is responsi‑ble to follow up and take action on that result.”
This initiative involves the EHR and IS&T (infor‑mation services and technology) teams, who are building a workflow for follow‑up and tracking within the EHR. Currently in proof‑of‑concept phase, the project looks at how keywords in the dictation and transcription processes might feed into the EHR to trigger automated workflows to track follow‑up actions for the incidental finding. The goal is that the keywords would initiate a work list for every step of follow‑up, including alerting the patient, tracking whether they came back for an appointment, and if they’re overdue for any actions necessary as a result of that appointment.
This initiative is only one example of several in the works at HealthPartners. Hull keeps her eyes
peeled for other opportunities. “Any time we have evidence‑based care and best practices, we’re trying to automate them through workflows in the EHR,” she says.
Dyad leadership—a clinician lead plus an operational lead—is another structure in place for initiatives across all areas of the organization. “Every clinic, every service line has a partnership. It’s a structure that’s been in place for a long time here. The physician leader partners with an operational leader to manage the business and all aspects of quality, safety, cost, etc., at every level of leadership, from the top down.”
Quality improvement work, Hull says, involves working with people, processes and technology.
“We start with where we want to be and what we need to do to get there. Whether it’s people, tools, IT support, communication, auditing—it runs the gamut. It’s a PDSA cycle—an improvement process where you plan, do, study, act, and then test and evaluate. That’s a constant in our lives every day. We never finish it, we just keep tweaking and evaluating and moving forward with it, making it better.”
ANNE GESKE
Managing Editor, Common Factors
“Executive sponsors are a key and critical step in good quality work.
We identify executive sponsors as well as
operational sponsors. We even have training
in our organization for the role of executive sponsor.”
Cara HullChief Quality Officer
HealthPartners
ConstellationMutual.com Table of Contents12 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 13
Creating Respectful
Care TeamsDisrespectful clinician behavior negatively impacts
patient care and the bottom line.
By J. Trout Lowen
14 / Common Factors / Spring 2019
We live in uncivil times. Bad behavior is on display everywhere—in the news, on our daily commutes, in line at the grocery store. The medical environment is no different. Rudeness, intimidation and bullying have long been identified as problems in the health care workplace. More than just an irritation, however, recent studies have shown that health care providers’ bad behavior can negatively affect patient outcomes and increase liability risk. Further, it may increase staff turnover and reduce patient satisfaction.
Although incivility and bullying behaviors are not exclusively an issue for physicians, physicians—particularly surgeons—rep‑resent the greatest risk to patient safety. A study published in the American Journal of Medical Quality in 20151 found correla‑tions between patient complaints, surgical occurrences and malpractice claims. The study examined 10,536 surgical cases involving 66 general and vascular surgeons and found that among surgeons who perform higher risk procedures, those who had a greater number of spontaneous patient complaints related to communication, respect or teamwork also had a greater likelihood of surgical complications and a higher risk of malpractice claims.
The study’s authors suggest that when a surgeon’s behavior is bad enough to prompt a patient to make a formal complaint, the surgeon’s behavior also has a negative effect on the surgical team and on performance, especially as the complexity, risk and stress related to the procedure increase. The study’s findings echo several earlier studies documenting a correlation between spontaneous patient complaints and an increased risk for malpractice claims.
Those findings do not come as a surprise to Laurie Drill‑Mellum, MD, Constellation’s chief medical officer. An analysis of Constellation medical professional liability claim data between 2012 and 2016 found that communication issues played a role in 35 percent of all liability claims and accounted for $131.4 million in costs. “Communication turns out to be an important contributing factor in our claims,” said Dr. Drill‑Mellum. “Physicians who have trouble with communication have an increased malpractice risk and poorer outcomes, and they themselves are isolated, from their peers and other health care team members.” Communication problems affect both the physician‑to‑patient/family relationship and communication between providers. Of the 35 percent of claims identified in the Constellation analysis, 65 percent involved communication between the provider and the patient/family; 42 percent involved communication between providers.
Other studies have raised additional concerns. The Institute for Safe Medication Practices (ISMP) conducted a national survey in 2013 of 4,884 physicians, nurses, pharmacists and risk/quality management staff,2 addressing the issue of disrespect‑ful behavior in health care. The survey, a follow‑up to a similar survey a decade earlier, found that despite awareness of the issue, little had changed: behaviors such as making negative comments about colleagues, condescension and insults, refusing to answer questions or return calls, and reluctance to follow safety procedures remain commonplace in the health care work environment.
These behaviors have broad impacts for patient safety. The ISMP survey found that 43 percent of respondents said their past experiences with intimidation affected the way they han‑dle order clarifications or questions about medication orders, and one third of the respondents said they had overlooked
When a surgeon’s behavior is bad enough to prompt
a patient to make a formal complaint,
the surgeon’s behavior also has a negative effect
on the surgical team and on performance.
“Physicians who have trouble
with communication have an increased
malpractice risk and poorer outcomes.”
14 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 15
concerns about a medication order rather than interact with an intimidating prescriber. “If you’re going to get your head chewed off, you’re not going to want to speak up,” said Dr. Drill‑Mellum, a career emergency room physician.
Communication breakdownOrthopedic surgeon Paul Damrow, MD, knows firsthand what can happen when hospital culture creates an environment where individuals are afraid to speak up. Dr. Damrow was chief of surgery for Park Nicollet Health Services in 2014 when a pro‑cedural error was committed during a surgery that could have resulted in the patient’s death. Fortunately, the error resulted in only a minor problem and the patient fully recovered.
But the incident was so concerning that Dr. Damrow and the hospital’s vice president of surgical services gathered the surgi‑cal team to conduct a root cause analysis to determine what led to the incident. During that process, it came to light that the cir‑culating nurse had been aware of the error at the time but did not speak up because she was afraid to question the surgeon.
“This was a communication problem,” Dr. Damrow says.In the wake of that incident, Damrow and Park Nicollet lead‑
ership decided they needed to strengthen the culture of safety within the institution. They organized a Safety Day and took the unusual step of shutting down the OR to all but emergency sur‑geries so all members of the surgical department could attend. Dr. Damrow brought in two pilots to talk about the aviation industry’s leading efforts to create a culture of safety, then par‑ticipants met with trained moderators in small groups for frank and open discussions of communication‑related problems.
If there was one central message of the day, Dr. Damrow says, it was that “silence is not an option. Everybody has the moral obligation to speak up if it looks like something is wrong.”
Creating a culture of safetySafety Day was one of several initiatives Park Nicollet imple‑mented to create a stronger culture of safety. Following the conference, Dr. Damrow let it be known that there would be zero tolerance for any surgeon who retaliated against a staff member for speaking up. Consequences could include suspen‑sion or firing.
The hospital also instituted a surgical huddle at the begin‑ning of each day to discuss that day’s procedures, and a short debrief after each surgery to discuss any issues. Like many other hospitals, they have also instituted a mandatory uniform timeout before each surgical procedure during which four members of the surgical team have to state the patient’s name, the procedure, the side of the body the procedure will be per‑formed on, the type of anesthesia, and whether an antibiotic has been administered. Surgery cannot start until the timeout is completed, Dr. Damrow says.
Another component of the hospital’s effort has been to empower patients to speak up. Poor hand hygiene is the most common cause of infection, and signs throughout the hospital and clinics now encourage patients to ask clinicians if they have
washed their hands. “When it first came out, a lot of us were insulted by that,” Dr. Damrow says. “And yet, the more you think about it, if that’s the most effective way of decreasing the number of hospital‑ or clinic‑based infections, why wouldn’t we do that?”
Have all of these measures improved safety? Dr. Damrow, who stepped down from his position as chief of surgery in 2015, hopes so. It’s hard to quantify culture change, he says, but one measure comes to mind: tracking the time between incidents of a retained foreign object. When he became chief, he says, it was not unusual to have three to four incidents a year. During his five‑year tenure, the hospital went more than 900 days with‑out an incident. “It was a source of pride for everyone,” he says.
A healthier work environmentIn addition to increased patient safety and reducing liability risk, creating a more open and collaborative culture can have other benefits for health care organizations seeking to attract physicians, nurses and other staff in a tight employment market.
“There is a shortage of nurses, a shortage of physicians, and a bolus of aging baby boomers who are going to have greater and greater health care needs,” Dr. Drill‑Mellum notes. “At the same time, you have a completely distressed and burned out medical and nursing workforce. The ones who are able to retire or walk away will.”
Patients, too, will vote with their feet. Aided by smartphone technology and websites that rate physician performance and rising health care costs, consumers are not going to stay with a physician who exhibits disrespectful behavior. “Clinicians who have social skills in addition to technical skills are going to do better,” Dr. Drill‑Mellum adds. “And clinics that serve those needs are going to have a competitive edge.”
References1. Catron TF, Guillamondequi OD, Karrass J, et al. Patient complaints and adverse surgical outcomes. Am J Med Qual. 2016;31(5):415‑22.
2. Grissinger, M. Unresolved disrespectful behavior in health care: practitioners speak up (again)—part 1. P&T. 2017;42(1):4,5,23.
J. TROUT LOWEN
Freelance Writer
“Clinicians who have social skills in addition
to technical skills are going to do better. And clinics that serve those
needs are going to have a competitive edge.”
16 / Common Factors / Spring 2019
1. ISMP, 2004. Intimidation: Practitioners speak up about this unresolved problem (Part I).
2. Grissinger, M. Unresolved disrespectful behavior in health care: practitioners speak up (again) – Part 1. P&T. 2017;42(1):4,5,23.
3. Lagoo J, et al., 2018. Multisource evaluation of surgeon behavior is associated with malpractice claims.
In 2003, the Institute for Safe Medication Practices (ISMP) conducted a national survey regarding intimidation in the workplace that showed such behavior was relatively common, perpetrated by both genders, and involved both peer‑to‑peer and interdisciplinary staff as well as physicians.1
In 2013, the ISMP conducted a follow‑up survey of 4,884 nurses, pharmacists, physicians and quality/risk management staff. In both surveys, respondents said physicians were the most common offender, but more than 40 percent said both physicians and other health care professionals engaged in such behaviors.2
Most common disrespectful behaviorsThe ISMP 2013 survey found that respondents encountered:
Negative comments about colleagues
or leaders
20% often
73% at least once
Reluctance or refusal to answer questions
or return calls
13% often
77% at least once
Condescending language, demeaning comments, or insults
15% often
68% at least once
Impatience with questions or hanging
up the phone
10% often
69% at least once
Reluctance to follow safety practices or
work collaboratively
13% often
66% at least once
Ripple effects on patient safetyThe ISMP 2013 survey found that respondents:
Had past experience with intimidating behaviors
that altered the way they handle order clarifications or questions
about medication orders
44%
Asked another professional to talk to a disrespectful prescriber on their behalf
about the safety of an order
38%
Assumed a medication order was correct and safe rather
than ask a particular provider to verify the order
63% of pharmacists
30% of nurses
Behaviors that reduce liability risk Behaviors that increase liability risk3
/ Being open to suggestions / Listening and paying attention to others / Informing others / Praising others / Exhibiting social awareness
/ Snapping at others / Talking down to others / Intimidating team members
Disrespect is Risky Behavior
ConstellationMutual.com Table of Contents16 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 17
A New Age for Senior CareOne leader shares his journey through relentless change.
By Liz Lacey-Gotz
18 / Common Factors / Spring 2019
Senior living is a booming business, led largely by the expected influx of baby boomers entering the market for care and housing. Estimated at approximately 47 million in 2017, the number of U.S. seniors is expected to skyrocket to nearly 100 million by 2060.1
Scott Riddle, CEO and president of Walker Methodist, has seen the business of senior care change significantly since he began working in the industry 14 years ago. “Our business model is undergoing an interesting shift. For the independent person, our communities have become a hospitality model, with more amenities and services. For those with higher care needs, we have become a medical model,” says Riddle. “People are coming to us with greater needs and acuity, and they’re coming later in life. The average age of someone coming into one of our independent living communities is mid‑80s. They’re coming in more frail, and they might come as independent but soon after, they are needing care.” This could lead to longer stays in a residence—statistics show that if a person reaches 80, they’re likely to live another eight to 10 years.1
Customer satisfaction is keyThe business model itself is changing—with customer service and satisfaction driving an increase in services extending well beyond health care into physical, emotional and spiritual needs.
“Today’s baby boomers coming into our communities are inter‑ested in wellness and fitness,” says Riddle. “So, we have fitness centers; we run classes and do individualized training. It’s not uncommon to see our fitness centers full of 85‑ to 90‑year‑olds working out!”
Addressing customers’ fitness needs—as well as offering continuous learning classes, outings, and arts and crafts—has other benefits: it helps seniors’ mobility, strength and alertness. They have less pain, and fall less often. Says Riddle, “It increases
Walker Methodist is a faith-based, non-profit senior living organization serving older adults since 1945. It owns, operates and manages 13 senior living communities and provides housing, health care, rehabilitation and services to seniors and the people who support them.
“For the independent person, our communities
have become a hospitality model, with more amenities and services. For those with higher care needs, we have become a medical model.”
Scott RiddleCEO and PresidentWalker Methodist
18 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 19
their overall wellness, so they feel better, they’re happier and they have more energy to be active.”
To understand customer needs, Riddle conducts surveys every month. “We try to survey 90 percent of the people in our communities every year. This includes patients and residents as well as their families. If someone has dementia, it’s impossible for us to ask them how we’re doing. So, we ask family members about several areas: cleanliness, quality of care, transportation needs, dignity and respect. But one of the most important things—to family members and to residents—is that they feel safe and secure. We are always trying to find ways we can make them feel safe and to assure them we take safety very seriously.”
Survey results have shown improvement overall every quarter for the last two years. According to Riddle, “We’re now above industry average in most of our categories, and we’re at best‑in‑class in several. Our goal is to be best‑in‑class in every category.”
Teamwork plus technologyEfficient and effective teamwork supported by new technology is at the heart of Walker Methodist’s efforts to keep up with the growth of senior care and the challenge of finding enough staff to support their residents and patients.
As soon as a new senior arrives, in coordination with the medical team, medical records are accessed, medications are reviewed, and determinations are made for immediate next steps. A resident will be introduced to their care team, which consists of physicians, NPs, RNs, nurse aides, social workers and dietitians. If the senior arrives after a surgery or other hospitalization, acuity is determined and follow‑up care is discussed and coordinated, including needs for assistance with the activities of daily life.
“The idea is to minimize what most people would call a tran‑sition,” says Riddle. “We want it to be seamless, so we make sure the team has access to the medical record through our systems. We make sure all providers involved know our policies, procedures and capabilities—how we do things, how we treat wounds, how we look at infections.”
Prevention is also important. Because falls are the leading cause of injury and death for adults over 651, it’s imperative to be proactive. Properly supervising and monitoring residents—using technology to check vitals regularly and to monitor all aspects of a resident’s health—helps alert staff to any concerns that could lead to a fall or other problems.
Efforts are made to minimize transportations and, as much as possible, to provide care at the residence. Like other health care sectors, senior care organizations are judged by rehospitalizations. “One of our goals is to do what we can to treat residents where they are,” says Riddle, noting that each senior residence has the technology to do their own labs, with a medical team available day and night. “Anytime you transport an elderly person, it can be traumatic,” says Riddle. “We are trying to do what we can to treat them in the best way possible. Sometimes that means sending them to the hospital, but
whenever we can, we treat them in the community.” Teleheath is also employed, if appropriate for the situation.
Recruiting and retaining talentRiddle identifies recruiting and retaining staff as the number one challenge in senior care in the next 10 years. “Quite frankly, it is a challenge for every industry. But it is a little more for us, because we cannot pay what a hospital does. Our reimburse‑ment is a fraction of what a hospital gets a day, so we can’t compete on price.”
Instead, Riddle’s teams work with schools and nursing programs to offer internships and residencies to help acquaint prospective staff with career opportunities in senior care. And they offer existing employees scholarships and flexibility to complete additional education, including RN or LPN degrees, or other administrative career tracks related to senior care.
Leadership and more strategic recruiting techniques have helped Walker Methodist build a culture and environment that people want to work in. “Number one, we have to attract good people. Number two, we need to retain them,” insists Riddle.
“People stay when the culture’s right and they feel respected and cared about.”
Riddle also points to the unique aspects of working with seniors, emphasizing the satisfaction that comes from develop‑ing meaningful relationships over time. “In our industry, if you are treating somebody, there’s a good possibility that you’re going to get to know them over weeks, months, years. And that’s a really rewarding part of our industry.”
More change to comeDespite the challenges, Riddle is excited about the future of senior living. “I’m definitely optimistic. There are a ton of challenges out there, but I think there’s also a ton of opportu‑nity. Every day, 10,000 people turn 65. They are living longer, and because they’re living longer, they are more likely to need senior care.”
The challenge is finding staff to take care of all these people. With fewer workers and skilled caregivers available, Riddle sees technology playing a key role in giving safe, quality care with less staff. “We can care for 10 people better now with one person than we could 10 years ago because of technology. So we need to continue to make improvements that could offer the same quality of care—or better—for 10 or 15 people with that one caregiver.”
Reference1. SeniorLiving.org Accessed November 28, 2018.
LIZ LACEY-GOTZ
Common Factors Editor
Constellation
ConstellationMutual.com Table of Contents20 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 21
Connecting with Self and Others Through EmpathyA review of “The Empathy Effect”
During moments of downtime in my recent travels, I have been reading “The Empathy Effect” by Dr. Helen Riess, MD (with Liz Neporent), a thoughtful and often moving account of empathy’s ripple effect. Dr. Riess has developed a program and tools focused on empathy that physicians and care teams can use to create a more positive impact on patient care. I believe these same tools can help all of us create deeper connections with each other. In fact, the subtitle of her book is “7 Neuroscience‑based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences.”
Dr. Riess uses the letters of E.M.P.A.T.H.Y. as a convenient way to help us understand and remember the tools we have at our disposal as we seek to communicate more empathically. E is for eye contact, M for the muscles used in facial expression, P for posture, A for affect, T for tone of voice, H for hearing the whole person and Y for your response—hopefully, a thoughtful response rather than a reaction.
I think my daughter was picking up on some of these cues years ago when, at age 3 or 4, she told me, “Dad, you are not listening with your eyes.”
I loved Dr. Riess’s analogy of a pebble dropped in a pond causing a ripple effect to describe how empathy can impact others. In medicine in particular, acts of empathy among care team members have a direct impact on patient expe‑riences and outcomes. “Distance and division aren’t necessarily geographic,” she notes. “What ripples into those outer rings may have as much to do with how
you see the world and how you think other people should live.”
Most of us are exposed to empathy as infants. Dr. Riess writes, “A focused gaze tells the baby she exists by reflecting to her that someone else is there. When a mother or father figure cradles a baby, studies show that the distance between their eyes is about twelve centimeters. Isn’t it remarkable that this happens to be the sharpest focal point for a new‑born infant?”
Two of my favorite sections in the book are titled “Good Enough is Probably Good Enough” and “The Neural Substance of Empathetic Leadership.” Many of us regularly deal with a child testing our limits of empa‑thy, especially those of us who parent teenagers. Dr. Riess suggests that, even if you don’t agree with or like a single word your child is saying, you should hear them out. And then (and this is the hard part), don’t comment. “One of the deepest longings of the human soul,” she notes, citing the words of the late Irish poet John O’Donahue, “is the longing to be seen.”
While leaders are often seen, the best ones listen with empathy and compas‑sion—more than they speak. These leaders, Dr. Riess says, have a clearly positive effect on neurological function‑ing, psychological well‑being, physical health and personal relationships.
The most important takeaway from “The Empathy Effect” for me was the concept of self‑empathy. “One reason we resist practicing self‑empathy is that we mistake it for self‑pity. We view it as
a soft and fuzzy euphemism for self‑in‑dulgence,” Dr. Riess says. “Self‑empathy requires greater self‑awareness, disci‑pline and sensitivity to self‑suffering.”
We all confront that unkind person in the mirror who tells us we are too this and too that. Maybe it’s time to discount that voice and realize that “good enough is probably good enough.”
BILL MCDONOUGH
President and CEO
Constellation
Book Review
ConstellationMutual.com Table of Contents20 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 21
Facts of caseA primary care physician (PCP) saw a 45‑year‑old woman for a routine exam and ordered a screening mammogram. The radiologist inter‑preted the mammogram as showing a region of potential distortion within the upper‑outer quadrant of the left breast and recommended additional imaging. The radiologist initiated an electronic process to generate and send a letter to the woman and a report to her PCP indicating that the mammogram showed find‑ings that required additional imaging studies to rule out disease.
One year later, the woman saw her PCP, complaining of a palpable lump in her left breast. The PCP ordered a mammogram that revealed a solid lesion in the upper‑outer quadrant of the left breast that was highly suspicious for cancer. The radiologist recom‑mended a biopsy of the lesion. Following the biopsy, she was diagnosed with breast cancer and underwent pre‑operative chemotherapy
followed by a mastectomy with sentinel node biopsy. She then underwent radiation to the left breast.
The woman filed a malpractice claim against the PCP, the radiologist and the radiology center alleging failure to timely diagnose breast cancer and lost chance of survival.
Disposition of caseThe malpractice case was settled against the radiologist and the radiology center.
Patient safety and risk management perspectiveThe investigation of this case revealed that the radiologist correctly interpreted the mammogram but a system‑generated letter to the patient and report to the ordering clinician were not sent due to a failure in the reporting technology. Neither the patient nor the PCP received the communications about the initial abnormal mammogram. A root cause analysis
Follow-up System Failure Leads to Missed DiagnosisA patient and her primary care physician do not receive communication about an abnormal mammogram, and a failure to timely diagnose breast cancer results.
SPECIALTY ALLEGATIONPATIENT SAFETY & RISK MANAGEMENT FOCUS
/ Radiology
/ Family practice
/ Failure to timely diagnose breast cancer
/ Follow‑up system failures
22 / Common Factors / Spring 2019
Claim Review
of this adverse event included a health information technology (HIT) investiga‑tion that found a recent software update triggered a failure in the reporting system and that many patients could have been affected.
The experts who reviewed the case were critical of the radiology center because they had no quality assurance process to test whether system‑gener‑ated letters and reports were received by patients and ordering clinicians. The PCP’s clinic was also criticized for not hav‑ing a follow‑up system in place to ensure that test result reports were received, reviewed and communicated for all ordered tests. The patient testified that she assumed “no news was good news” when she didn’t receive communication about the mammogram results.
Preventing follow-up system failuresThe Mammography Quality Standards Act (MQSA) requires a radiology practice that performs mammograms to prepare a written report of the results of any mammography examination signed by the interpreting physician, provide the written report to the patient’s physi‑cian(s) and provide a written letter to the patient in terms easily understood by a lay person. Most radiology practices use an electronic system to generate patient letters and reports to ordering clinicians, as well as track biopsies and follow‑up exams. Most primary care clinic EHRs have the capability to track comput‑er‑ordered tests for receipt, review and patient notification. Safety audits of these systems can indicate whether they are working correctly and identify gaps in follow‑up processes before a patient is injured.
Radiology and primary care practices can perform a failure modes and effects analysis (FMEA), a prospective process, on test management and reporting processes to identify where and how the process might fail, the likelihood the failure will be detected, the effect of the failure on the patient, and what can be
Support during an adverse outcome and malpractice claimFor many clinicians, clinics, hospi‑tals and senior living organizations, facing an adverse event and mal‑practice claim is a real possibility. A claim can have a significant impact on clinicians, care team members and the organization.
The aforementioned radiologist was deeply affected by the filing of this malpractice claim. While she had correctly read the mammo‑gram, she felt guilt over the failure of the communication system and the possibility that many more patients could be affected. Our claim team was able to connect her with our Clinician Peer Support program staff, who helped her to manage those emotions and use that energy toward performance improvement. Our risk and patient safety consultants were able to help both the radiology and primary care practice analyze their follow‑up systems, re‑engineer safer systems and implement safety audits to ensure the systems continued to work.
Constellation provides resources and support for clini‑cians and care team members to
keep them focused and productive after an unexpected outcome and malpractice claim, including:
/ Information about what to expect in the claim and litiga‑tion process
/ Clinician Peer Support program: counseling and support to address the emotional impact of adverse events, including burnout and second vic‑tim syndrome
/ Resources to understand the relationship between burnout and the potential for future adverse events and claims
/ Help to create internal peer support teams
/ Resources and coaching on apology and communication processes that support clini‑cians, team members, patients and their families
/ Education and resources to recognize the risks to patient safety/malpractice claims
/ Education and resources to create a learning culture so that the experience of an adverse event can be used to improve performance
done to prevent the failure. Using the results of the FMEA, processes can be re‑engineered to be more reliable and safe. A root cause analysis (RCA) can also be performed after a failure to diagnose event like this to determine the causes and contributing factors of the event to make processes safe and reliable.
HIT team members or consultants can assist radiology practices with the integration of imaging systems with a closed‑loop follow‑up workflow that includes patient letters, ordering clinician reports and summaries, biopsy results,
and recommendations and tracking reminders. HIT team members can also assist primary care practices in fully implementing the tracking features of their EHRs.
LORI ATKINSON, RN, BSN, CPHRM, CPPS
Content Manager and Patient Safety Expert
Constellation
ConstellationMutual.com Table of Contents22 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 23
Facts of caseFamily members found a 75‑year‑old woman with a history of diabetes and dementia on the floor of her bedroom in an agitated state after an apparent fall. Her family called an ambulance, and she was transferred to the local hospital emergency department (ED) for evaluation. While in the ED, she became com‑bative, exhibited paranoia and was admitted to the psychiatric unit for treatment.
A hospitalist performed the admitting history and physical and wrote admission orders for insulin, as well as orders for glucose monitoring four times a day. The attending psychiatrist wrote orders for Haldol®, Zyprexa and trazodone. In consultation with her family, court commitment proceedings were initiated because an assessment indicated she would be unable to return home due to her paranoia, dementia and cognitive decline.
After four weeks of hospitalization, while waiting on the commitment proceedings,
the insulin was discontinued, and an oral antidiabetic medication was added by the hospitalist. After six weeks of hospitalization, her family was able to find her a room in a senior living memory care unit. The discharge summary listed two oral antidiabetic medi‑cations, daily glucose monitoring, as well as Haldol and Risperdal®. The discharge summary was electronically signed by the psychiatric attending physician.
Five days after admission to the memory care unit, she was observed exhibiting jerky movements and was unable to hold herself upright in a chair. The care team notified the nurse practitioner on call, and a telephone order was received to adjust her Haldol dosage. Late the next day, she was found unresponsive in her room and EMS was called. She was severely hypoglycemic and was transferred by ambulance to the ED where she was intubated and admitted to the intensive care unit. An MRI showed an ischemic stroke
Communication Chaos at Transition of CareAn elderly diabetic patient with dementia is discharged from a hospital to a senior living memory care unit with orders for duplicative doses of diabetes medication leading to severe hypoglycemia, seizures and death.
SPECIALTY ALLEGATIONPATIENT SAFETY & RISK MANAGEMENT FOCUS
/ Psychiatry
/ Hospitalist/hospital
/ Senior living/ memory care
/ Improper treatment and monitoring of diabetes and medication error resulting in death
/ Breakdowns in communication at transitions of care
/ Medication reconciliation
Breakdowns in communication between a hospital and post-acute care center at transition of care are a frequent cause of patient injury.
24 / Common Factors / Spring 2019
Claim Review
and her EEG was minimally responsive. Her family elected to have her extubated with palliative comfort care only. She died two weeks later due to an anoxic brain injury from prolonged hypoglyce‑mia and an acute ischemic stroke.
Her family filed a malpractice claim against the psychiatrist and the senior living center alleging improper treatment and monitoring of diabetes and medica‑tion errors.
Disposition of caseThe malpractice case was settled against the hospital and senior living center.
Patient safety and risk management perspectiveThe investigation into this case revealed that the woman was receiving two anti‑diabetic medications in error after being admitted to the memory care unit. She was taking metformin prior to discharge from the hospital, but the discharge orders included both metformin and glimepiride. The root cause analysis could not pinpoint why the glimepiride was listed on the electronic discharge summary and transfer orders.
Because the psychiatrist was listed as the prescribing physician on the discharge summary, the family filed a claim of negligence against him for the medication error. The psychiatrist testified that psychiatric attending physicians manage only the mental health medications and the hospitalists manage the medical condition medica‑tions. However, because the patient was on a psychiatric unit, the EHR‑generated discharge summary listed the psychiatrist as prescribing the discharge medications. The investigation also revealed some confusion about whether the woman was to have glucose monitoring. The transfer orders included daily glucose monitoring but the memory care admitting nurse did not transcribe those orders onto the care plan.
The experts who reviewed this case were critical of the hospital and psychiat‑ric unit for not having a reliable process
to reconcile medications prescribed by multiple clinicians at the time of discharge. The senior living memory care center was criticized for not reconciling transfer medications, not questioning the double antidiabetic medication orders, not recognizing hypoglycemia, and not performing glucose checks as ordered that could have identified the low glucose level before it became severe.
Risk and resident safety solutionsBreakdowns in communication between a hospital and post‑acute care center at transition of care are a frequent cause of patient injury, including readmission to the hospital, permanent disability and death.
In our analysis of Constellation pro‑fessional liability claims involving skilled nursing, assisted living and independent living facilities asserted from 2010 to 2015, improper management of treat‑ment and improper resident monitoring were the second and third most common and costly claims and together represent one‑third of all the claims in the analysis. The contributing factors to these claims involved errors in clinical judgment (crit‑ical thinking skills), improper monitoring of resident physiologic status, and break‑downs in communication among the care team concerning the resident’s condition.
Readmission quality measures for post‑acute providers (skilled nursing and home health care) are now in effect. CMS’s Skilled Nursing Facility Readmission Measure now affects post‑acute provider compliance and business outcomes.
Skilled nursing, senior living, home health and related organizations should have reliable processes to reconcile and communicate medications at transitions of care. The process should include clarification of questionable orders and review for potentially harmful medica‑tion interactions or contraindications. Using a team approach and including a pharmacist on the team enables the team to competently evaluate admission, discharge, and transfer medication orders to prevent injury and malpractice claims. Post‑acute care organizations should also have a reliable process to identify an acute change of condition in a patient/resident and promptly notify the attending clinician.
LORI ATKINSON, RN, BSN, CPHRM, CPPS
Content Manager and Patient Safety Expert
Constellation
Questions for senior leaders
The following questions may help identify the next steps to take to enhance patient/resident safety and minimize risk:
� Does your organization have a reliable medication recon‑ciliation process, including a pharmacist on the care team?
� Do you provide education and training to boost care team member critical thinking skills, monitoring skills and recognition of an acute change in condition?
� Does your organization provide education and training on the use of team communication tools such as SBAR or IPASS?
ConstellationMutual.com Table of Contents24 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 25
Are Your Opioid
Pain Management Practices Current?
The opioid addiction crisis continues to dominate headline news. According to the Centers for Disease Control and Prevention (CDC), in 2016, 40 percent of opioid over‑doses involved prescription opioids, with more than 46 people dying every day.1 The most common drugs involved in prescription opioid overdose deaths are methadone, oxycodone and hydrocodone.
While the overall prescribing rate of opioids has been declining since 2012, the amount of opioids prescribed in 2015 remained approximately three times as high as in 1999 and varied substantially across the country.2 There is continuing evidence of problematic prescribing patterns. In 2017:
/ There were still almost 58 opioid prescriptions written for every 100 Americans3
/ 17 percent of Americans had at least one opioid prescription filled, with an average of 3.4 prescriptions dispensed per patient
/ The average number of days per prescription continues to increase, with an average of 18 days in 2017.3
A review of Constellation medical professional liability (MPL) claims asserted from 2010 to 2015 found that opioids were involved in 19 percent of claims where medi‑cation was a factor, and 24 percent involved more than one medication. The opioids most involved were hydromorphone, methadone and oxycodone. The combination with the highest indemnity and severity was fentanyl and oxycodone. Death was the outcome in 22 percent of all cases.
Technology and a team‑based approach can increase patient safety and reduce risk.
By Lori Atkinson, RN, BSN, CPHRM, CPPS
26 / Common Factors / Spring 2019
Clinicians continue to face scrutiny of their opioid prescrib‑ing practices through DEA investigations, state medical board sanctions and medical professional liability claims—and for good reason. Some clinicians and organizations still are not using best practices outlined by the CDC, state boards, and other organizations.
Following current best practices can prevent harm and protect organizations from allegations of negligent prescribing, overprescribing, and failure to recognize and treat opioid use disorder (OUD).
A settled malpractice claimA recent claim, settled on behalf of a primary care physician
(PCP) and his clinic involved a 37‑year‑old man with complaints of low back pain who was treated with multiple opioids and muscle relaxants for over 10 years. In the early years of treat‑ment, the PCP examined the man up to seven times a year and wrote up to 38 prescriptions per year for various opioids. Over the years, the dosages and the number of pills increased.
In the last two years of treatment, the PCP did not perform any physical exams on the man and wrote 15 opioid prescrip‑tions. Another PCP diagnosed the man with OUD and he entered a rehabilitation facility for treatment. The man filed a malpractice claim against the first PCP alleging over‑prescrib‑ing of opioid pain medications resulting in OUD and failure to diagnose and timely treat OUD. He also filed a claim against the PCP’s clinic alleging failure to supervise and monitor clinician opioid prescribing practices.
Our investigation into the claim revealed the following problems in defending the PCP and the clinic:
/ Increasing dosages and prescriptions of opioids with limited or no physical exams
/ Sparse documentation of exams and diagnostic testing to identify and treat the source of ongoing low back pain
/ Family history of substance abuse not taken into consideration
/ Lack of tools and processes to assess and monitor patients receiving opioid prescriptions
/ Failure to obtain informed consent; lack of documentation of patient education
/ Lack of a process to monitor the prescribing practices of the clinic’s clinicians
Keep current on best practicesReducing injuries in patients being treated with opioids
and the resulting malpractice claims can be accomplished by implementing the following:
1. Use a team-based approach, which redistributes roles and accountabilities across the team and empowers team members to work up to the scope of their license and education. A team‑based approach to workflows ensures that clinicians have time to spend with complex chronic pain patients. Redesign workflows to assure tasks are appropriately and efficiently delegated to team members in these areas:
/ History intakes and updates / Medication reconciliation / Review of the prescription drug monitoring program in
your state / EHR documentation during and after exams / Follow‑up system that track exams, refills, tests, test results
and referrals / Patient education, goal setting and coaching / Monitoring of pain patient dashboards
2. Employ technology to automate processes: / Embed documentation templates and risk assessment tools
into the EHR to capture and document pertinent medical history, family history, risk factors for OUD and mental health status.
/ Create a patient dashboard view of pain status, functional and goal status, risk level, opioid prescriptions, morphine milligram equivalents (MME) dosages, refills and requests, test results, monitoring status and referral status.
/ Run reports from the EHR to identify outstanding lab test reports, referral reports and patients due for exams and testing.
/ Create a clinician opioid‑prescribing dashboard, and include a feedback loop for individual clinicians on their opioid prescribing practices.
References1. Seth P, Scholl L, Rudd RA, Bacon S. Overdose deaths involving opioids, cocaine, and psychostimulants – United States, 2015‑2016. MMWR-Morb Mortal W. 2018;67(12):349‑358.
2. Centers for Disease Control and Prevention. Vital Signs: Changes in Opioid Prescribing in the United States, 2006‑2015. MMWR-Morb Mortal W. 2017;66(26):697‑704.
3. Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug‑Related Risks and Outcomes – United States. bit.ly/2CBstY4 Published 2018. Accessed December 4, 2018.
LORI ATKINSON, RN, BSN, CPHRM, CPPS
Content Manager and Patient Safety Expert
Constellation
A team-based approach to
workflows ensures that clinicians have time to spend with
complex chronic pain patients.
ConstellationMutual.com Table of Contents26 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 27
LAURIE C. DRILL‑MELLUM, MD, MPH
Elephant in the Room
Courageous leaders need to stand up to incivility
in the health care workplace.
28 / Common Factors / Spring 2019
Meditations on Medicine
Last month, I was asked to deliver a talk on “bullying in health care” for a local hospital’s monthly grand rounds. I called my talk “What we do and say matters: The costs of incivility in health care.”
When I told medical friends and colleagues that I was delivering this talk—not once, but twice—in the course of four weeks to two groups largely com‑prised of physicians, many of whom are surgeons, I got the response that Lurch on the Addams family used to give when he thought one of the family’s ideas was crazy: a shaking of the head with lots of dubious and anxiety‑provoking grunts. People seemed to think I was being either naive or coura‑geous and optimistic to think I could broach such a topic, one addressing behaviors that are ingrained, perpetuated and tolerated in medical and nursing cultures. Based on my sample of two large groups, I saw both heightened interest in the topic of incivility as well as uncertainty about how to tackle it.
One place we don’t have uncertainty, for the most part, is identifying incivility. We know it when we see it, when we hear it, and by marking how we feel when we witness or experience it. As one of my colleagues who has worked with hundreds of leaders in health care addressing behavior in the workplace notes, “When you ask about harmful behavior, everyone gets it right—from children to adults.” The challenge is less about identifying it than about ensuring a culture and leadership committed to addressing it. (See Resources.)
During my presentation, I used an audience engagement tool to poll participants on their experience with harmful behaviors in the workplace during the past year. I asked about behaviors spanning the continuum from being given the silent treatment to being yelled at, threatened or demeaned. For almost all items, 64–92 percent of respondents had either witnessed or been the recipient of the negative behaviors “a few times” or
“several times” in the past year. Disturbing results.From my research, I can definitively state that
there are real costs to incivility, from diminished employee and patient experiences to staff turnover to adverse clinical outcomes to, ultimately, reduced financial returns. I believe the time has come to address this problem. It will take strong leader‑ship, courage, commitment and tools—as well as accountability—to succeed.
Parker Palmer, author, educator and founder of the Center for Courage and Renewal, challenges leaders to stand in what he calls “the tragic gap” between reality and possibility. He elaborates: “On one side of that gap are the harsh and discouraging realities around us. On the other side is the better world we know to be possible—not merely because we wish it were so, but because we have seen it with our own eyes.”
It’s time we stand up and address the “elephant” in our house of medicine, the better to focus on the world we know is possible.
Resources“A Hidden Wholeness: The Journey Toward an Undivided Life,” by Parker J. Palmer
Behavior at Work Collaborative: behavioratworkcollaborative.org
“Crucial Conversations: Tools for Talking When Stakes are High,” by Kerry Patterson, Joseph Grenny, Ron McMillan and Al Switzler
“Teaming: How Organizations Learn, Innovate, and Compete,” by Amy C. Edmondson
LAURIE C. DRILL-MELLUM, MD, MPH
Chief Medical Officer
Constellation
People won’t remember
what you said, but they will
remember how you made
them feel.
— Maya Angelou
ConstellationMutual.com Table of Contents28 / Common Factors / Spring 2019 Common Factors / Spring 2019 / 29
Calendar
AHCA/NCAL AND ASHRM INVITE CONSTELLATION EXPERTS TO SPEAK AT ANNUAL EVENTS
On October 15, Constellation Content Manager and Patient Safety Expert Lori Atkinson, RN, BSN, CPHRM, CPPS, will speak on “Preventing and Reducing Falls: Using Malpractice Claim Data to Guide Changes” at AHCA/NCAL’s 70th Annual
Convention & Expo in Orlando, FL. Go to AHCANCAL.org/events for more information.
Constellation Senior Risk and Patient Safety Consultant D. Michelle Kinneer, PhD, JD, MSN, RN, CPHRM, CHPC, CHC, will speak in October on “The Resilient Risk Manager: Steps to Strengthen Emotional Intelligence” at
ASHRM’s Annual Conference in Baltimore, MD. Go to ASHRM.org for more information.
UMIA RISK MANAGEMENT EDUCATION
Please save the date for UMIA’s upcoming Risk Management Education events. UMIA experts will share insights you can use to improve patient safety.
Current topic:
/ Surviving and Thriving through a Claim: Finding support and preventing adverse outcomes
Tuesday, April 9, 6–8:30 p.m. Provo Marriott, Provo, UT
Tuesday, May 7, 6–8:30 p.m. Great Falls Hilton Garden Inn, Great Falls, MT
Tuesday, May 14, 6–8:30 p.m. Casper Hilton Garden Inn, Casper, WY
Tuesday, May 21, 6–8:30 p.m. Jackson Hole Snow King, Jackson Hole, WY
Tuesday, June 25, 6–8:30 p.m. Cheyenne Fairfield Inn & Suites, Cheyenne, WY
Thursday, August 15, 6–8:30 p.m. Missoula Hilton Garden Inn, Missoula, MT
Tuesday, August 20, 6–8:30 p.m. Bozeman Hilton Garden Inn, Bozeman, MT
Tuesday, September 10, 6–8:30 p.m. Ogden Hilton Garden Inn, Ogden, UT
Tuesday, September 17, 6–8:30 p.m. Kalispell Hilton Garden Inn, Kalispell, MT
Tuesday, October 1, 6–8:30 p.m. St. George Hilton Garden Inn, St. George, UT
Tuesday, November 26, 6–8:30 p.m. Salt Lake City Little America, Salt Lake City, UT
To register, contact Carol Merryman at [email protected] or call 800-748-4380 / 801-716-3221. For event questions, contact Cynthia Tyhurst at [email protected].
MMIC SPEAKING ENGAGEMENTS
On June 6, MMIC Senior Risk and Patient Safety Consultant Betty VanWoert, RN, BSN, CPHRM, will speak on “Vital Signs for Team Communication: Avoiding Life Support” at the 2019 Nebraska Healthcare Quality Forum at
Embassy Suites by Hilton Omaha LaVista Hotel and Conference Center in LaVista, NE.
On June 18, MMIC Senior Risk and Patient Safety Consultant Kristi Eldredge, RN, JD, CPHRM, will speak on “Evolving Models of Care: Eight Questions to Ask Before Diving into Telemedicine” at the IRHA Annual
Conference at the French Lick Resort and Conference Center in French Lick, IN.
MMIC RISK MANAGEMENT EDUCATION
MMIC experts will share insights you can use to improve patient safety.
Topics include:
/ Team Strategies for Complex, Resource-Intensive Care / Surviving and Thriving through a Claim: Finding support and preventing adverse outcomes
Tuesday, April 30, 10:30 a.m. to 2:45 p.m. Embassy Suites Omaha LaVista Hotel & Conference Center, LaVista, NE
Tuesday, May 7, 10:30 a.m. to 2:45 p.m. Holiday Inn & Suites at Jordan Creek, West Des Moines, IA
For more information, contact Angela Churchill at [email protected]
Contact MMIC 7701 France Avenue South Suite 500Minneapolis, MN 55435
952.838.6700 | 800.328.5532Fax: 952.838.6808Policyholder technical support800.328.5532
Contact UMIA 310 East 4500 South, Suite 600Salt Lake City, Utah 84107-3993
Phone 800.748.4380Utah Phone 801.531.0375Montana Phone 800.748.4380
Idaho Phone 800.748.4380Wyoming Phone 800.748.4380Fax801.531.0381
ContactARKANSAS MUTUAL INSURANCE 11300 N. Rodney Parham Road
Suite 220Little Rock, AR 72212
P: 501.716.9190F: 501.716.9193
7701 France Ave SouthSuite 500Minneapolis, MN 55435
