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Your Presenters Today Are…….2
Becky Simer RN BSNetwork Performance Improve Manager for p g
IA/NEPCA
And
Linda Ruble ARNP PA
Clinical Consultant for HRSA and IA/NEPCA
Clinical Risk Clinical Risk Management: 101g
3
AN OVERVIEW PRESENTATIONF O R
MIDWEST CLINICIANS NETWORKMIDWEST CLINICIANS NETWORK
WEBINAR & PHONE
THURSDAY, OCTOBER 8, 2009
DEFINITION of “RISK MANAGEMENT”4
RISK: The possibility of loss or injury; peril; a dangerous element
MANAGEMENT: The act or art of conducting or supervising something or the judicious means to supervising something or the judicious means to accomplish an end.
RISK IN HEALTHCARE: The probability that something undesirable will happen –implied need for avoidance.avoidance.
THINK: Murphy’s LawTHINK: Murphy s Law
If 5
If something something
can go can go wrong, it wrong, it
will…will…
SO, PREPARE!!!Our goal is to identify the y“dangerous elements” in our
i t environment, processes and products and products, and minimize the possibility of loss, injury, and…. (yes) peril.
6
FTCA (Federal Tort Claims Act)( )Claims Data2004 - 20084
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THERE ARE 937 FTCA DEEMED
HEALTH CENTERS, REPRESENTING
87% OF THE TOTAL NUMBER OF
HEALTH CENTERS (CY2009)
HRSA National Medical ClaimsSTATE INFO:
h // h / / i i / /
Total Claims by Nature of Occurrence (2004 ‐ 2008)
https://eroom.hrsa.gov/eRoom/LearningCommunity/PCAroom/0_2e44 8
60
80
0
20
40
2004 2005 2006 2007 2008
Diagnosis Related 54 48 68 75 67
Obstetrics Related 55 68 57 55 73
Treatment Related 54 31 25 53 59
Medication Related 19 25 16 33 35
2004 2005 2006 2007 2008
Surgery Related 7 14 15 10 22
NULL 24 22 3 15
Other Miscellaneous 6 3 1 5
HRSA Medical ClaimsStandard of Care Met or Not Met
Standard of Care (2004 ‐ 2008)9
133 126 92008
85 100 7
121 96 26
2006
2007
117 86 27
91 97 28
2004
2005
0% 20% 40% 60% 80% 100%
Met Not Met Unable to Determine
HRSA Claims by Secondary Factors IdentifiedIdentified
Secondary Factors Identified (2004 ‐ 2008)
10
120
140
40
60
80
100
0
20
Documentation 106 100 80 120 139
Policies/Protocols/Procedures 103 77 65 125 114
2004 2005 2006 2007 2008
/ /
Training/Lack of Supervision 37 87 72 110 134
Communication 3 28 21 93 89
No Secondary Factors Found 50 29 51 38 42
Referral Issues/Recurring Complaint 15 5 4 39 19
St ffi /A il bil it /S h d li 24 4 8 9 18
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[FOR THIS PRESENTATION
ONLY]
This SymbolThis Symbol,
Represents
EMR
Project
Enhancement
↓
Primary Liabilities forPROVIDERSPROVIDERS
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Lack of documentation of treatment
Inadequate work-up (based on accepted standards)
Acts of others (e.g. nurses) if exercising control
Failure to follow upFailure to follow up
Mistaken identity (provider and center)
Mi di i if b d i d i i d iMisdiagnosis, if based on inadequate examination and testing
Wrong diagnosis followed by improper treatment causing injury
MORE Primary Liabilities for PROVIDERS13
Wrong treatment or procedure based on diagnosis.
Treatment outside field of competence (or not privileged for)Treatment outside field of competence (or not privileged for)
Abandonment (neglect or failure to follow up after the acute stage of illness – unilateral termination of the physician patient relationship without notice to the patient)
Failure to obtain full informed consent
Failure to see consultation or refer to a medical/surgical specialist
Use of unprecedented procedures, unless approved by a respectable minority of medical opinionp
MORE Primary Liabilities for Providers
Failure to order diagnostic tests that are considered to be a
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g“matter of common knowledge”
Failure to obtain results of diagnostic tests orderedFailure to obtain results of diagnostic tests ordered
Infections resulting from failure to utilize proper procedures or precautionsprecautions
Aggravation and/or activation of a preexisting condition if injury resultsresults
Premature dismissal or discharge of patient
Primary Liabilities Primary Liabilities of NURSES
Administration of drugs inconsistent with prevailing statutes,
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Administration of drugs inconsistent with prevailing statutes, nurse practice acts, or institutional policies
Failure to follow provider ordersFailure to follow provider orders
Failure to report significant concerns or changes in a patient’s condition
Failure to take correct verbal or telephone ordersFailure to take correct verbal or telephone orders
A FEW More for NURSES…16
Patient burns
P ti t f llPatient falls
Failure to report defective equipmentFailure to report defective equipment
Failure to follow established policies or procedures
Negligent handling of patient valuables
What About “Negligence”?17
As a basis for malpractice
• “Proper Care” is based on a defined standard established by law to protect others malpractice,
negligence means lack
law to protect others against harm; in medical malpractice, “proper care” is judged by peers;means lack
of proper or reasonable
y p
• “Reasonable Care” means there is both a rationale for doing and
careg
for not doing, and that rationale is the basis for decision making
NEGLIGENT CONDUCT
Doing what a reasonable person would not do
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Doing what a reasonable person would not do
Failure to do what a reasonable person would do:
• Exercise reasonable care• Protect or assist another
[Contributory negligence: A plaintiff’s proven contribution to his or her own harm, perhaps forcing f f it f l i ]forfeiture of claim]
BURDEN OF PROOF forNEGLIGENCE
ALL THREE (3) elements must be proven!!! 19
1) BREACH of DUTY – Based on policies or procedures, or reasonable standards of care (laws, regulations, or peers)DUTY
Ensure patient’s safety throughout “transaction” (visit)Protect from foreseeable harmProtect from malpractice
2) MEASURABLE HARM -- (Injury)2) MEASURABLE HARM (Injury)
3) CAUSATION – (The breach of duty caused the injury)
Highest Number of Claimsin AMBULATORY CARE by SPECIALTYin AMBULATORY CARE by SPECIALTY
Internal Medicine TOP ALLEGATIONS
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TOP ALLEGATIONS• Failure to diagnose• Failure to perform
Family Practicep
surgery• Improper performance of
tests or procedures
Ob/Gyn
tests o p ocedu es• Delay in diagnosis• Improper management
of course of treatmentOb/Gyn of course of treatment• Failure to communicate • Lack of informed consent
RISK MANAGEMENT is….
An ORGANIZATIONWIDE PERFORMANCE IMPROVEMENT PROCESS
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IMPROVEMENT PROCESS
considered by most references to be one key component of the giant quality umbrella
Risk management needs good outcomes; d t i d litgood outcomes require good quality
management
Quality
Management
22
g
Good
Risk Management
Good Outcomes
QI and RM Share…
A commitment to eliminate or reduce problems in patient care and maximize patient safety
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patient care and maximize patient safety
Concern for prevention of harm and loss
EFFECTIVE RISK MANAGEMENTS EMPHASIZES “HARM PREVENTION” FOR PATIENTS, HARM PREVENTION FOR PATIENTS,
VISITORS AND STAFF MORE
THAN FINANCIAL LOSS.
RISK MANAGEMENT andRISK MANAGEMENT andQUALITY MANAGEMENT
GO “HAND-IN-HAND”
“QUALITY IS THE OPTIMAL
GO HAND IN HAND24
“QUALITY IS THE OPTIMAL ACHIEVEMENT OF THERAPEUTIC
BENEFIT AND AVOIDANCE OF RISK AND MINIMIZATION OF
HARM.”T H E J O I N T C O M M I S S I O N J O C O S S O
QI and RM Share…
Improved processes for QI enhances RM
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Improved processes for QI enhances RMBoth benefit from efficient resource utilization and minimal effort duplicationBoth are committed to reducing problems for patients and maximizing their safety and good careBoth are concerned for prevention of harm and loss.Both are concerned for prevention of harm and loss.
RISK MANAGEMENT and QUALITY IMPROVEMENT h t l have mutual “CAUSATIVE, POSITIVE CORRELATION”!!!
CLINICALCLINICALRISK MANAGEMENT
FOR
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FOR
AMBULATORY CLINICS
RISK MANAGEMENT Specific toAmbulatory Clinics or Health Centers
Patient scheduling must be defined by written protocols.
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Patient scheduling must be defined by written protocols.
Have clear guidelines for triage, especially for emergency d t i itand urgent visits
Missed appointments should be brought to the providerd doc mented in the medical eco dand documented in the medical record
Keep appointment records for as long as the clinic records are keptare kept
Maintain clear policies for triage or urgent visits and stick to themto them
RISK MANAGEMENT Specific toAmbulatory Clinics or Health CentersAmbulatory Clinics or Health Centers
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Have written policies for patient tracking of referrals and diagnostic follow up
• Log labs, diagnostic tests and referrals; keep tickler fileg g p• If serious and cannot contact patient, send certified letter
Keep tickler of recommended preventative testing and document informed refusals
• One role is held accountable for maintaining up-to-date follow up
Keep medication sheet in MR with date, name of med ordered, dose, quantity, # of refills, provider’s initials, staff initials, and any adverse reactions.
Document and check allergy status consistently
RISK MANAGEMENT Specific toAmbulatory Clinics or Health Centers
Referrals
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Referrals• Document referrals in chart with timeframes• Document conversations between providers• Send pertinent records• Include all patient communications• Develop procedure to monitor receipt of
consult reports• Providers must review and initial ALL
t b f ddi t MRreports before adding to MR
Patient Education
Review all written materials for accuracy before adopting th
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them
Create policies for readability regarding health literacy and l l di i i d i i lcultural diversity in education materials
Maintain a master file and archived files of all patient d l l h d deducation materials along with dates used
Have patients confirm understanding of instructions and p greturn demonstration if applicable
Ask provider and patients to sign off on important p p g pinstructions
RM for Clinics
Give and get report after practice coverage. Put documentation in patient charts
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Locum Tenens: Credentialing and privileging is essential, along with abbreviated orientation
Triage Policy and Telephone Protocols:
• Consider checklist form organized by S/S or pt. complaint• With triage, err on the site of caution with appointments. or referrals to
urgent care or ER• PULL CHART and check medical record if symptomatic
Receptionists can handle administrative calls but NURSES SHOULD HANDLE CALLS THAT INVOLVE PATIENTS WITH SYMPTOMS. These calls should be documented in the medical recordrecord.
INFORMED CONSENT
Remains a persistent basis for liability claims
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Remains a persistent basis for liability claims
Responsibility belongs to the care provider who is to conduct the proposed test or treatmentproposed test or treatment
Support staff may have the patient read but not sign, prior to the provider’s review with the patientprovider s review with the patient.
Exceptions:
• Life threatening illness or injury needing immediate attention• Patient cannot communication or take part in communication• There is no time to secure treatment authorization from someone else who is
l ll d t t ti t’ b h lflegally empowered to act on patient’s behalf.
MEDICAL ERRORS
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“ A N A C T O F C O M M I S S I O N ( D O I N G
S O M E T H I N G W R O N G ) O R O M I S S I O N
( F A I L U R E T O D O T H E R I G H T T H I N G ) T H A T ( F A I L U R E T O D O T H E R I G H T T H I N G ) T H A T
L E A D S T O A N U N D E S I R A B L E O U T C O M E O R
S I G N I F I C A N T P O T E N T I A L F O R S U C H A N S G N C N O N O S U C N
O U T C O M E ”
“CATEGORIZATION” of Medical Errors
“A ti E ” t th “Sh E d” t
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“Active Errors” or errors at the “Sharp End” occur at point of contact between a human and some aspect of the system (e.g. instrument, machine) or patient
“Latent Errors” or errors at the “Blunt End” occur through failures of organization, design, or layers of the g g , g , yhealthcare system affecting the human making contact
“Error Chain” is a series of events that lead to an Error Chain is a series of events that lead to an adverse outcome, typically uncovered by a “root cause analysis” (Swiss Cheese Model)
Taking a Risk with Swiss Cheese Demonstration35
http://lessons.workforceconnect.org/reflib/defanp // g/ /
The SWISS CHEESE ERROR Model36
And “TYPES” of ERRORS
Error: Failure of a planned action to be completed as intended
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p por use of a wrong plan to achieve an aim
Adverse Event: An injury resulting from a medical interventionAdverse Event: An injury resulting from a medical intervention
Serious Error: An error causing permanent injury or transient but potentiall life threatening harmbut potentially life-threatening harm
Minor Error: An error causing harm that is neither permanent nor life threateningnor life-threatening
Near Miss: An error that could have caused harm but did not, either by chance or interventioneither by chance or intervention
Most Common Medical Errors (IHI)38
Missed and delayed diagnoses
Medication errors
Delayed reporting of results
Miscommunications during transitions in care
UNDERLYING CAUSES ofMEDICAL ERRORS (IHI)
Communication problems
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Communication problems
Inadequate information flow
H f l d blHuman factors-related problems
Patient-related issues
Organizational transfer of knowledge
Staffing patterns and workflowg p
Technical failures
Inadequate policies and proceduresInadequate policies and procedures
SBAR (Situational Briefing Model)(Situational Briefing Model)
SBAR facilitates clear communication between staff
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SBAR facilitates clear communication between staff and providers
SBAR is a standardized situational briefing model
BEFORE using SBAR and talking to provider:
• Assess the situation• Assess the situation• Know the primary diagnosis• Read recent progress notes, assessments, and labs• Have chart or medical record available• Have chart or medical record available
SBAR (pronounced ‘S’-bar)
SITUATION (I d t t ll b t )
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SITUATION – (I need to tell you about…)
BACKGROUNDBACKGROUND
ASSESSMENT -- (what has changed)ASSESSMENT -- (what has changed)
RECOMMENDATIONRECOMMENDATION
http://www.ihi.org/ihi/topics/patientsafety/safetygeneral/tools/sbartechniqueforcommunicationasituationalbriefingmodel.htmg
MEDICATION ERRORS
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EVENTS RELATED TO MEDICATIONS
A RE THE THIRD-LEADING CAUSE OF
DEATH IN THE US AFTER HEART
DISEASE AND CANCER
MEDICATION Errorsin Clinics
Incorrect prescribed dosage
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p g
Incorrect medication for diagnosis or condition
Multiple pharmacy prescriptions
Medication incompatibility
Inappropriate dispensing of sample medsInappropriate dispensing of sample meds
Illegible handwriting on prescriptionsg g p p
Verbal Orders? No, no!!
Verbal orders (VOs) are a major cause of medication errors
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VOs should be eliminated except in emergency situations
As an extra check, spell unfamiliar drug names, with “T for Tom” and “C for Charlie”
Pronounce each numerical digit separately saying “one six” instead of “sixteen” to avoid confusion with “sixtyconfusion with sixty
The receiver must ensure that the verbal order makes sense with the patient’s diagnosis
IF VOs are allowed, prescribers must enunciate; receiver should always repeat the order to the prescriber to avoid misinterpretation
The MANDATORY READ BACK policy is essential for critical lab results alsoThe MANDATORY READ BACK policy is essential for critical lab results also
OTHER RISK MANAGEMENT RULESTO PREVENT MED ERRORS
Al t th i di ti f th di ti th d
45
Always put the indication for the medication on the order
Order should be complete including strength & concentration of medication, route, and rate of administration (if applicable)
Do not use any abbreviations or use very sparingly
NEVER use “DO NOT USE” abbreviations
Verbal orders are used in emergencies only
Script pads are locked and stored away from patient care
Never pre-sign or post-date prescriptions
MORE MEDICATION ERROR RISK MANAGEMENT RULES
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Track manufacturer lot numbers
Avoid samples (or review policies for RM)
Monitor expiration dates and remove outdates
Keep medication samples locked
L b f l i i h ld b Lot numbers of any samples given to patients should be recorded in the medical record
High Risk Patient Populations
Renal/liver impairment
47
/ p
Pregnant/breastfeeding patients
Neonates
Elderly/chronically ill patientsde y/c o ca y pat e ts
Patients on multiple meds
Patients with multiple co-morbidities
Oncology patientsOncology patients
It d tIt comes down toCOMMUNICATION
48
60% of med errors are caused by mistakes in interpersonal mistakes in interpersonal
communication. (Joint Commission)
I t d ti t Introduction to National Patient Safety Goals
P R O V I D E D C O U R T E S Y O F T H E
J O I N T C O M M I S S I O N
y49
J O I N T C O M M I S S I O N
FOCUSING ON THOSE RELATED TO
MEDICATION ERRORSMEDICATION ERRORS
Accurately & completely RECONCILE MEDICATIONS across the continuum of care (Goal 8)
“ h ( b ) f i h
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“There (must be a) process for comparing the
patient’s current medications with those ordered
for the patient while under the care of the
organization.” g
The Joint Commission
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_amb_npsgs.htm
Medication Reconciliation
When a patient is referred to or transferred from one
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porganization to another, the complete and reconciled list of medications is communicated to the next provider of service and the communication is documented.
When a patient leaves the organization’s direct care directly to his/her home, the complete & reconciled list of medications is
id d t th ti t’ k PCP th i i l f i provided to the patient’s known PCP, or the original referring provider, or a known next provider of service.
h i l h i i ’ l & When a patient leaves the organization’s care, a complete & reconciled list of the patient’s medications is provided directly to the patient & the patient’s family as needed, and this list is explained to the patient and/or family explained to the patient and/or family.
“DO NOT USE” ABBREVIATION LISThttp://www.jointcommission.org/PatientSafety/DoNotUseList/
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There are TONS of TIPS for“Implementing Elimination of
Dangerous Abbreviations”…
HTTP://WWW JOINTCOMMISSION ORG/
g53
HTTP://WWW.JOINTCOMMISSION.ORG/
PATIENTSAFETY/N A T I O N A L P A T I E N T S A F E T Y G O A L S / A B B R _ T I P S . H T M
L k Alik S d Alik M dLook Alike – Sound Alike Medsfor AMBULATORY CARE
“LASA” MEDICATIONS
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LASA MEDICATIONS
HTTP://WWW.JOINTCOMMISSION.ORG/N R / R D O N L Y R E S / C 9 2 A A B 3 F A 9 B D 4 3 1 C 8 6 2 8N R / R D O N L Y R E S / C 9 2 A A B 3 F - A 9 B D - 4 3 1 C - 8 6 2 8 -
1 1 D D 2 D 1 D 5 3 C C / 0 / L A S A . P D F
Confusing Drug Names
•Losec (Omeorazole) and Lasix (Frusemide)
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•Avanza (Mirtazapine) and Avandia (Rosiglitazone)
C l b (C l ib) d C b (F h i )•Celebrex (Celecoxib) and Cerebyx (Fosphenytoin)
and Celexa (citalopram hydrobromide)
•Reminyl (Galantamine) and Amaryl (Glimepiride)
•Diamox (Acetazolamide) and Zimox (Amoxicillin)
•Lamisil (Terbeniafen) and Lamictal (Lamotrigine)
•Taxol (Paclitaxel) and Taxotere (Docetaxel)
More Confusing Drug Names
Avandia (rosiglitazone) and Coumadin (warfarin)
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Catapres (clonidine) and Klonopin(clonazepam),
Concentrated Roxanol and oral morphine liquid (traditional concentration)
Hydromorphone injection and morphine injection
Insulin products• Humalog and Humulin, Novolog and Novolin, Humulin and Novolin, Humalog and Novolog, Novolin
70/30 and Novolog Mix 70/30
Lorazepam (Ativan) and alprazolam (Xanax)
T ( i ) d T l l ( l l)Topamax (topiramate) and Toprol-xl (metoprolol).
Flagyl (metronidazole) and Glucophage (metformin)
Z ( l i ) d Z t ( ti i i )Zyprexa (olanzapine) and Zyrtec (cetirizine)
RISK MANAGEMENT for “LASA’s”
Consider when adding to formulary
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Use both brand names and generic names when possible
Change appearance of look-alikes on labels and records by bolding, highlighting, or enlarging the letters that are different
Change order on computer screens so they don’t appear consecutivelyChange order on computer screens so they don t appear consecutively
Store in different locations in pharmacyStore in different locations in pharmacy.
Employ independent double checks in dispensing: one interprets and enters into computer; another reviews the printed label against the original prescriptioncomputer; another reviews the printed label against the original prescription
Who would imagine confusion between h d ?these two products?Zyrtec or Lipitor?
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How about even “high-risk di ti ”?medications”?
Avandia or Coumadin
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ISMP (I tit t f S f ISMP (Institute for Safe Medication Practices))
H A S P R O V I D E D A L I S T O F
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HIGH ALERTMEDICATIONS
( S E E A T T A C H M E N T )
HIGH ALERT HIGH ALERT MEDICATIONS
“ H I G H A L E R T M E D I C A T I O N S ” A R E D R U G S T H A T B E A R A
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“ H I G H - A L E R T M E D I C A T I O N S ” A R E D R U G S T H A T B E A R A
H E I G H T E N E D R I S K O F C A U S I N G S I G N I F I C A N T P A T I E N T
H A R M W H E N T H E Y A R E U S E D I N E R R O R .
A L T H O U G H M I S T A K E S M A Y O R M A Y N O T B E M O R E
C O M M O N W I T H T H E S E D R U G S T H E C O N S E Q U E N C E S O F A NC O M M O N W I T H T H E S E D R U G S , T H E C O N S E Q U E N C E S O F A N
E R R O R A R E C L E A R L Y M O R E D E V A S T A T I N G T O P A T I E N T S .
HIGH ALERT MEDICATIONShttp://www.ismp.org/Tools/highalertmedications.pdfp // p g/ / g p
62
HIGH ALERT MEDICATIONS (ISMP):Purpose of Listp
Improving access to information about these drugs
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Improving access to information about these drugs
Limiting access to high-alert medications
Using auxiliary labels and automated alerts
Standardizing the ordering, storage, preparation, and administration of these products
Employing redundancies such as automated or independent double checks when necessary
THE RISK MANAGEMENTTHE RISK MANAGEMENTPLAN
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AND ITS ESSENTIAL COMPONENTS!
HRSA FTCA (Federal Tort Claims Act) DIRECTION
PAL 2009-05 (http://bphc.hrsa.gov/policy/pal0905/)
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Application requires information on the following health center activities:
• Risk Management Systems• Board approved Quality Assurance/Quality Improvement Plan• Board approved Quality Assurance/Quality Improvement Plan• Clinical protocols• Patient records management• Patient follow up and tracking• Incident tracking and reporting• Incident tracking and reporting• Peer review/staff training
• Credentialing Systems• Primary Source Verification
V ifi ti f d ti d t i i b d tifi ti f i l f • Verification of education and training, board certification, professional references, health fitness,
• National Practitioner Data Bank (NPDB) query • Formal Privileging ProcessP f i l Li bilit Hi t• Professional Liability History
RM Plan Should Include At Minimum:
Policy or statement of purpose
66
o cy o state e t o pu pose
Goals
Scope, including linkages with QM, case management, patient safety, and safety management
Authority and responsibilities of:
• Governing body• Administration• Physicians/Licensed Independent Practitioners• Risk Manager, Quality Manager, Patient Safety Officer(s), Case
Management Director, and other roles
RISK MANAGEMENT PLAN: Additional Componentsp
C fid i li d C fli f I P li i
67
Confidentiality and Conflict of Interest Policies
Data sources and referrals
Documentation and reporting mechanisms
Integration of activities and information
P l iProgram evaluation
Organizational charts and flow charts as applicableO g pp b
RISK MANAGEMENT PLAN: Standards68
FOR EXAMPLE:
Risk Management is a leadership (governing body, administration, g p (g g b y, ,medical/professional staff, management) activity linked to quality and safety
Regarding quality and safety, leaders are responsible for organization wide planning for structures and process, establishing priorities for Performance Improvement, including high-risk procedures.…., and designing new or modified processes, while implementing an integrated patient safety modified processes, while implementing an integrated patient safety program.
Include Description of RM Model and SystemsSystems
DO include organizational model and/or vision (“just culture”) as well as
69
DO include organizational model and/or vision ( just culture ) as well as safety standards, audit practice, and guidelines for occurrence or incident reporting
DO describe tracking & analysis mechanisms for RM and QI
DO NOT use an originating occurrence reporting form itself in any peer review activities. Abstract important information onto a practical tool to utilize for the review
DO NOT document the name of the person originating the occurrence report. It is adequate to state that the issue originated in QM
RM Models and Systemsy70
FOR SINGLE SITE OR MULTIPLE SITE
CLINIC SETTINGSCLINIC SETTINGS
Organizational Models forRisk ManagementRisk Management
71
A RM Committee (may be closely linked to QI Committee: subcommittee or regular component of QI agenda)
A RM Director or Coordinator (may be part of QI or Compliance role)
S per isors and managers ork ith designated RM Lead • Supervisors and managers work with designated RM Lead to report occurrences and potential adverse events; possible risk factors; and department specific and organization wide safety initiativesorganization wide safety initiatives
Smaller Clinics: Center Manager or Director incorporates risk management plan into daily operations
Clinical Risk Management Models
Early Warning System
72
Early Warning System
An organization-wide system to screen all patients
and systems for real or potential adverse incidents,
issues, and occurrences that might result in
increased risk to the organization and/or less than
optimal quality of care
Clinical Risk Management Models
Generic Screens -- Used to concurrently screen every ambulatory
73
Generic Screens Used to concurrently screen every ambulatory patient encounter for given time periods. Covers all important aspects of a visit; or may be modified according to specific concerns or services
• A general adverse outcome criteria set serves a warning for a A general adverse outcome criteria set serves a warning for a claim or increased risk, which is then proactively addressed. This method is statistically effective in identifying nearly all occurrences.
Adverse Patient Occurrences (APOs) – Unexpected untoward events with actual or potential negative impact on the patient
Potentially Compensable Events (PCEs) -- Those APOs that might become claims based on the degree of actual or potential negative impact on the patienton the patient
Clinical Risk Management Models forPredicting Adverse Eventsg
74
Use analysis and historical data to predict potential for adverse occurrence, degree of risk, and to estimate financial impact on the organization in case of occurrence
Prioritize risks by frequency, severity, and potential for reduction
Investigate potential risksInvestigate potential risks
Map processes and systems and analyze for risk reduction
Utilize PDSA’s to identify improved processes to eradicate identified risk
DATA COLLECTION DATA COLLECTION AND ANALYSIS
75
COLLECTION AND ANALYSIS
OF RELATED DATA IS AN OF RELATED DATA IS AN
ESSENTIAL COMPONENT OF
ALL EFFECTIVE RISK
MANAGEMENT PLANS
Continuous Measurementof Risk Management Dataof Risk Management Data
Occurrence reporting
76
Performance measures
Quality and utilization management screening
Surveillance, audits, and surveys
External review data/denials
Patient satisfaction/dissatisfaction and complaints/grievances
Financial audits and billing disputes (primarily financial but can overlap with clinical)
Continuous Measurementof Risk Management Dataof Risk Management Data
Root Cause Analyses (RCA), Failure Mode and Effect Analyses , special studies
77
Grapevine information system and anonymous reporting
Physician/nurse referrals
Safety and other committees
Observation of daily operations and care
R i f Review of contracts
Making the Data MEANINGFUL78
Analyze all data in a variety of relationships and perspectives to identify t d iktrends or spikes
Utilize PDSA’s or other improvement initiatives (start small and do pilots initiatives (start small and do pilots first) to address trends before they become big problems.become big problems.
Other Significant RM Data
Review:
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Review:• Any recent or current liability claims
C h ti t’ di l d • Cases where patient’s medical records are requested
• Case types identified through literature review, Case types identified through literature review, news media, or new state or federal law
• Practices that may create liability• ALL occurrence or incident reports
OCCURRENCE Vs. INCIDENT?
Occurrence Reporting uses generic screening to
80
p g g gcatch APOs. RM determines which APOs may be PCEs • Supports ongoing data collection, tracking, trending, and
analysisanalysis• Allows timely intervention• Allows identification of areas for preventive action
Incident Reporting is the oldest method of risk identification and analyzing loss potential
Is largely anecdotal• Is largely anecdotal• Is an internal source for actual or potential compensable
events• Is historically an administrative documentation system • Is historically an administrative documentation system
and is generally considered “discoverable”
Occurrence/Incident ReportTracking and Analysis
Set up an organizational system for
81
Set up an organizational system for tracking occurrences
According to service line• According to service line• According to problem or cause, or type of problem or
cause• Is advantageous to categorize in multiple ways to ensure
accurate tracking (systems, processes, time, place)• Use this as a tool to track and trend systems problems or y p
issues in certain services• Include categories for equipment problems and
medication problems, and ensure appropriate follow upp , pp p p
National Patient Safety Foundation
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E N C O U R A G E S A L L W O R K E R S T O A C C E P T
R E S P O N S I B I L I T Y F O R T H E S A F E T Y O F
T H E M S E L V E S T H E I R C O W O R K E R S T H E M S E L V E S , T H E I R C O W O R K E R S ,
P A T I E N T S A N D V I S I T O R S
BREAK TIME / INTERMISSION83
COMMUNICATION
Insurance claims administrators and medical 84
Insurance claims administrators and medical liability defense attorneys estimate that communication failure is a contributing factor in 80% of all professional claims and lawsuitsof all professional claims and lawsuits
In 20% of the cases, it is the primary reason for the filing of the lawsuit.
Provider Communication
J O I N T C O M M I S S I O N H A S B U I L T S E V E R A L
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J O I N T C O M M I S S I O N H A S B U I L T S E V E R A L S T R A T E G I E S T O I M P R O V E
P R O V I D E R C O M M U N I C A T I O N
I N T O
N A T I O N A L P A T I E N T S A F E T Y G O A L S
E4 Component of Clinical Care
1) ENGAGEMENT
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)Greet by name with patient fully clothed (both the patient and the provider)
Be curious about the personBe curious about the person
Learn person’s agenda, including goals and all complaints
2) EMPATHYValidate expressed fears, concerns, symptoms, and pain
Sit, maintain eye contact, remove physically barriers
Learn to have open and relaxed body language
E4 Component of Clinical Care
3) EDUCATE – about the encounter, diagnosis, etiology,
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treatment options and follow upAssess current knowledge
Assume there will be questionsAssume there will be questions
Reassure patients that there will be time available for them to ask questions
E ti t d t d i f ti id d b ki th t Ensure patient understands information provided by asking them to restate
4) ENLISTMENT –Invitation to patient to collaborate in decision making and compliance.
Many patients have a self diagnosis. Provide rationale for yoursy p g y
ANGRY or DIFFICULT?
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THIS IS NOT A TYPE OF PATIENT, BUT
A CLINICIAN EXPERIENCE. (SORRY…)
The experience is based on interaction between the patient and the provider
Difficulties stem from frustrations (either
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Difficulties stem from frustrations (either party), inflexibility, and misaligned expectationsexpectations
• Be aware that anger is expressed both verbally and non-verballynon verbally
• Acknowledge the patient’s anger or dissatisfaction.• Establish the goal to assist him or her in expressing
d l i i h b ibl and resolving concerns in the best possible manner• Allow the patient to express her/his anger in a
private area, away from other patients.p ate a ea, a ay o ot e pat e ts.
Frustrating or Difficult Visits(continued)
Demonstrate empathy
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Demonstrate empathy
Focus on content rather than delivery of patient’s message
Use self disclosure cautiously and when appropriate
After the patient has vented, respond by talking about those issues that can be readily resolved
Enlist patient in the problem solving and get his/her input before Enlist patient in the problem solving and get his/her input before determining plan of action
DOCUMENT EVERYTHING, omit nothing.
How to Handle an Adverse Outcome or Potential Adverse Event
COMMUNICATION is an essential liability
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yavoidance measure
DISCLOSURE is core in management of clinical crises, adverse outcomes, unanticipated events,
di l d di l i hmedical errors, and medical mishaps
F i h ld bli h d For consistency, centers should establish and use similar terms and nomenclature for DISCLOSURE
DISCLOSURE METHODS
DISCLOSURE MODELSOne person (RM or QI)
DISCLOSURE STRATEGIES
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One person (RM or QI)
Team Model (RM, Manager, Key Staff involved)
J i Ti Di l
STRATEGIESAcknowledgement that the event occurred
C i ti f tJust in Time – Disclose at the point of care or adverse event. This is the ideal model
Communication of regret
An apology
Objective statementsthe ideal model (transparency)
What occurred
Event is being investigated
Steps will be taken to avoid precurrence
Remain in close contact with pt. and family till resolvedp y
“Best Practice” Communication93
Failure to communicate effectively is responsible for the vast majority of avoidable accidents
Replace top down communication with bi-directional i icommunication
A majority of healthcare workers regularly see colleagues break rules, make mistakes, fail to offer support, and/or appear critically incompetent. LESS THAN 20% SAY ANYTHING ABOUT IT!ABOUT IT!
How to Implement a pReliable and Consistent
Occurrence Reporting System
O R
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O R ,
“ P L E A S E D O N ’ T F I R E T H E M E S S E N G E R !
MYTHS that PREVENTOCCURRENCE REPORTINGOCCURRENCE REPORTING
“If I can make it right it’s not an error ”
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If I can make it right, it s not an error.
“If it’s not my issue it is not an error ”If it s not my issue, it is not an error.
“If another patient’s needs took priority over this, it is not an error ”error.
“A ‘Clerical’ (documentation) error is not a real med error.”
“If my actions prevent something worse, it is not an error.”
C ti “JUST CULTURE f Creating a “JUST CULTURE of Safety”
“ T H E M E D I C A L C U L T U R E T H A T S I L E N T L Y T A U G H T
y96
“ T H E M E D I C A L C U L T U R E T H A T S I L E N T L Y T A U G H T
T H E A B C ’ S A S A C C U S E , B L A M E A N D C R I T I C I Z E I S
F A D I N G . R I S I N G I N I T S P L A C E I S A S A F E T Y
C U L T U R E E M P H A S I Z I N G B L A M E L E S S R E P O R T I N G ,
S U C C E S S F U L S Y S T E M S , K N O W L E D G E , R E S P E C T ,
C O N F I D E N T I A L I T Y , A N D T R U S T . ”
D R . T O M H E L L M I C H O F P A T I E N T S A F E T Y C O U N C I L
For Decades, Occurrence Reports Often Ledto Termination
Staff were afraid to report errors or near misses for
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errors or near misses for fear of repercussions to themselves or their co-workers.
If asked to fill one out by a i t ff f lt lik supervisor, staff felt like
there was automatic blame placed on the one pwho wrote or reported it.
Transition from Punitive Responseto “Blameless” Reporting
There was an interim period in the late 80’s and 90’s
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p 9termed a “non-punitive culture.” This raised concerns that people who acted recklessly would not be held
t bl Whil l d hi t lk d “ iti ” accountable. While leadership talked “non-punitive,” occurrence reporting continued to be avoided by many employees fearing repercussions and blame for employees fearing repercussions and blame for reporting errors.
Creating the “JUST CULTURE” in Healthcare
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Lucien Leape, Harvard surgeon, father of recent patient safety movement, introduced the “just culture”… “Having a safety culture doesn’t mean there is no role for punishment. Punishment is indicated for willful misconduct reckless behavior indicated for willful misconduct, reckless behavior, and unjustified, deliberate violation of rules… but not for human error.”
More on the “JUST CULTURE”David Marx, Attorney in HR and Organizational Development
Providers and Leaders in a ‘just culture’ must:
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Providers and Leaders in a just culture must:• Recognize that professionals make mistakes• Acknowledge that even professionals will use shortcutsg p• Support zero tolerance for reckless behaviors• Openly admit that, “I have made a mistake.”• Call out when they see risk• Call out when they see risk• Participate in a learning culture (where information about
mistakes and near misses is shared with others so they can prevent similar situations )prevent similar situations.)
• Must be sensitive to risk, as they try to identify where and how the next mistake might occur, and then work to prevent it form happeningit form happening.
“SILENCE KILLS: THE SEVEN CRUCIALCONVERSATIONS IN HEALTHCARE”CONVERSATIONS IN HEALTHCARE
Book by Stacy Nelson, EdD: Referenced by Joint Commission recommendations—
il kill
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www.silencekills.com
This book and the study it details is the first attempt to This book and the study it details is the first attempt to link people’s ability to discuss emotionally and politically risky topics in a healthcare setting with ke es lts inkey results in:
Patient safety
Quality of careQuality of care
Decreased turnover in nursing
This study identifies SEVEN categories of conversation which areof conversation which are…
especially difficult and at the same
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…especially difficult, and at the same time appear to be especially essentialfor people in healthcare to master:for people in healthcare to master:• Broken rules
Mistakes• Mistakes• Lack of support• Incompetence• Incompetence• Poor teamwork• Disrespectp• Micromanagement
Benefits of “Tough” Conversations
The study shows that the 10% of healthcare workers
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The study shows that the 10% of healthcare workers who are confident in their ability to raise those “sensitive” concerns:
• Experience better patient outcomes• Work harder
A ti fi d• Are more satisfied• And are more committed to their jobs
A primary goal for healthcare leaders is to create an A primary goal for healthcare leaders is to create an environment that encourages open discussion and transparency in these sensitive conversations.
Suggestions for Leadership to EncourageOpenness in “Sensitive” TopicsOpenness in Sensitive Topics
“Have you observed any actions or omissions that could have
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Have you observed any actions or omissions that could have caused patient harm but didn’t? Tell me about it.”
“Do you feel comfortable speaking to other care providers if you feel they are jeopardizing patient safety? Do you feel comfortable reporting lapses you observe in patient safety? Why or why not?”
“Can you tell me about a time when a patient was harmed? Tell me how you think that happened and your ideas on how we could prevent it from happening again ”prevent it from happening again.
Occurrences may appear to increase at first, but that is due to more honest and realistic reporting of actual and potential to more honest and realistic reporting of actual and potential adverse events.
Leaders in Risk Management
Change Agent:
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Change Agent: • Uses PI processes for & in RM and RM processes for &
in PIin PI• Part of PI team: identifies RM and safety related issues
in PI projects and points them out constructivelyE hi th t ’ l ti • Encourages researching other centers’ solutions; frequently uses PDSA’s
• Actively opens up “silo” mentality in center or organization
• Uses a team-based model with all stakeholders involved in solutions, including patients when possibleo ed so ut o s, c ud g pat e ts e poss b e
Leaders in Risk Management
Prioritize and advocate for safety above financial and
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yoperational goals
Encourage and reward identification, communication, and l ti f f t iresolution of safety issues
Provide for organizational learning from accidentsg g
Allocate appropriate resources, structure, and accountability to maintain safety systemsmaintain safety systems
Absolutely avoid modeling reckless behavior in any form or in management decisionsmanagement decisions
Leadership Pitfalls107
B
Leadership Pitfalls
• Beware of introducing a NEW BE
• Beware of introducing a NEW risk by implementing a solution whose implications h t b f ll d W
A
have not been fully assessed.
• Do not change a process based AR
• Do not change a process based on one disastrous occurrence, without assessing a “special
i i ”E
cause variation.”
High Quality Care is Safe Care108
Remember, it’s really all about
idi f providing safe, quality care for our
patientspatients.
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Any questions, please feel free to call or write:p
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Becky Simer, RN [email protected]
Linda Ruble, PA [email protected]@ianepca.com
(W)515-333-5014(C) 515-868-8458
[email protected](H) 515-255-4147(C) 515-778-3318 (Never
ll h d i i t answers cell when driving – a part of her personal risk management plan!)
THANK YOU!!!
