Title: Risk Management: Best Practices to Optimize Prevention
1Risk Management Best Practices to Optimize
Prevention
- All-Grantee Meeting, Washington D.C.
- June 24, 2008
- Petra S. Berger PhD RN, CPHRM
- Healthcare Quality, Risk Patient Safety
Consultant - pberger_at_rmpsi.com - Phone 517281-7816
2 Learning objectives
- Discuss concepts and tools of risk management,
patient safety and integration with quality
improvement - Describe ten clinical risk factors (process
outcome) common _at_ Health Centers, along
with strategies of risk prevention control
3VITAL BRIDGE OVER TROUBLED WATERS
- QUALITY MANAGEMENT
- Patient Safety Q. I. Risk
Management identify risk respond
prevent
4DIVERSE QUALITY RISK GOALS on O N E
Platform
- Efficiency Cost control
- Access to care Referral mgt
- Patient Satisfaction
- Clinical Effectiveness
- Regulatory compliance
- Patient Safety vs. error, delay, omission
5PURPOSE x 3 RISK MANAGEMENT
- STOP PREVENT HARM
- Patient Advocacy
- PROTECT the Healthcare facility from
- litigation and financial loss
- patient and community distrust
- PROTECT involved Providers Staff
6Health Center Trends and Issues
- Claims Occurrence
- Error in Diagnosis 30
- Treatment related 21
- Medication related 10
- OB Related 22
- Surgical Procedures 6
- Claims Location
- Health Center 65
- Hospital 35
7Liability Analysis Allegation of NEGLIGENCE
- Duty based on existing provider-patient
relationship - To exercise degree of care that a reasonable
- competent provider would exercise under same
- or similar circumstances
- Breach of Duty
- Plaintiff must show that defendant failed to
exercise - reasonable care, and adherence to
- established clinical standards (expert testimony)
- Injury proximately CAUSED by breach (foreseeable)
8Case Example Medication Monitoring
- 58-year-old male patient is scheduled for a major
diagnostic procedure at the hospital where a
certified registered nurse anesthetist (CRNA)
provides conscious sedation. - A required copy of the clinic medical record is
sent preoperatively. No mention is made of the
patients seizure medication.
9Case Example Medication Monitoring
- No recent blood level had been obtained related
to the patients seizure medication. - Patient compliance with the medication was
unknown. - The patient underwent scheduled procedure
- The patient experienced a grand mal seizure
during the procedure and had a respiratory
arrest. Intubation was delayed and the patient
suffered permanent brain damage.
10Liability Analysis Duty? Breach? Injury?
Damages?
- A. Standard of Care - prelude to Q. measures
- Monitoring patient medication document
- Test result reported to signed off by provider
- Patient notified documented
- Treatment plan updated, w/ or w/out change
- Medical records accurate comprehensive
- B. CRNA hospital standards of care
11PRIMARY STRATEGY OF RISK CONTROL Risk
Identification Analysis
- Event or Claims review Root Cause analysis
- Incident reporting - adverse event (1 - 30)
- Omitted or delayed diagnostic workup
- Adverse medication event
- Patient or family complaint or feedback
- Staff feedback surveys
- Risk reporting marathons snapshots
- Occurrence Screens
- Missed appointments Waiting times
12Risk process 1 Patient communication
- Patient assessment interview
- Treatment planning Goal contracting
- Non compliance Termination of care
- Informed Consent / refusal
- Health instruction literacy interpreters
- Explain back / read back
- Patient feedback complaints
13Informed Consent or refusal
- Used whenever an invasive procedure is proposed
that carries a risk of harm - Medical Provider has discussion of the
- Procedure and benefits (P)
- Risks of the procedure ( R)
- Alternatives to the procedure (A)
- Questions asked (Q)
- What should be documented?
- Consent process, any questions answered
14Complaints Regulatory requirements
- CMS CoP - Infraction of patient rights IF
- Evidence of non responsiveness
- Non-resolution of complaint or grievance
- Complaint verbal, informal, promptly resolved
- Grievance req. investigation 7d TAT appeal
- Develop PP w/ time frame implement
- Inform patients on how to report a concern
- Use grievance committee as needed
- Pt Complaints GrievancesNo Leeway for Lapses
in Resolution RMPSI IE - 08/13/07
15Complaints Preventive factors
- Organizational Factors
- Culture of Patient centeredness
- Certain care processes that invite complaint
- Medical Provider Staff Factors
- Communication skills Clinical skills
- Time pressure, fatigue, frustration
- Patient Factors
- Difficulty understanding feeling abandoned
- Stress of diagnosis, finance, grief, fear
- Somatizing non adherence
16Disclosure What and How
- Known Facts s/p investigation
- Same as documentation, medical record
- SUMMARY Sequence of events
- SUMMARY Discovered Cause(s) per evidence
- Clinical results effects on patient
- Corrective actions taken no staff names
- Empathy concern expressed to patient
- Apology if error made and harm caused
17Risk Process 2 Organizational Provider
Communication
- Flow Availability of Organizational Information
(P P, Staff Educ., Pt. Info., MR) - Inter-provider team relations conflict mgmt
- Communication breakdowns occur during hand-off at
transition points from one provider to another --
verbal written - Communication barriers are cause of 2/3 of
serious medical errors (JC reports)
18Risk process 3 Litigation review
ofMEDICAL RECORD DOCUMENTATION
- ?Treatment rationale ?Diagnostic Follow Up
- Omissions \ delays in needed care
- Contradictions confusion between provider
- Finger pointing subjective statements
- Corrections Write overs White out
- Illegibility error prone abbreviations
- Altered Medical Records Late entries
- Do not mention incident report completed
19Risk process 4 Clinic Operations (systems)
- Continuum of care (62 claims) F. U.
- vs. Fragmentation across settings
- Referral management
- Diagnostic test tracking
- After hours coverage Telephone triage
- Access to care No shows
- Missed Appointments
- Tickler system, patient return for annual exams,
FU tests, preventive screens
20Risk process 5 Clinical Practice
- Medical evaluation Treatment
- Complex medical conditions Cancer, Co-morb.
- Medication therapy Pre-natal risk factors
- Pre- and post-surgical patient evaluation
- Use of Practice Guidelines decr. variability
- Asthma, Anticoagulants, Stroke, Pediatric Fever
- Guarding against Complications (preventable)
- OB, Surgical procedures, Emergency
- Sample protocols can be accessed at
http//www.guideline.gov/
21Risk Outcome 6 Diagnostic Error, Delay,
Oversight
- Most frequent
- Cancer Myocardial infarction Stroke
Meningitis Acute abdomen Fractures Prenatal
risk factors Infections post surgical - Factors
- Atypical signs symptoms
- Incomplete or inaccurate information about
medical history many co-morbidities - Insufficient diagnostic work up Delays
22Confirmation Bias
- Paris in the
- the Spring
- Once we decide that we know what something
is, we tend to exclude or neglect information
that may be contrary to our original perceptions
23 Diagnostic Test tracking per Flowchart
Checklist
- Test ordered by med. provider log
- Request form created - copy retained
- Test completed - patient compliance?
- Results received and logged in / ck log
- Results reported to provider (same day for
abnormal /critical value results) - Patient notification documented
24Risk process 7 Medication Safety
- Adverse Medication events related to phases
- Product labeling, packaging, nomenclature
- Prescribing Indications, interaction, off label
- Antibiotics, anticoagulants, narcotics,
cardiovascular, steroids - Dispensing compounding, distribution error
- Administration wrong drug/ dose/ route
- Source National Coordinating Council on
Medication Error Reporting and Prevention
www.nccmerp.org
25Risk process 8 EQUIPMENT EOC EMERGENCY
RESPONSE
- Emergency protocols implemented and monitored for
- Medical emergency
- 1 BLS trained staff on-site at all times
- Crash cart (incl. pediatrics) checks
- Behavioral emergency
- Building /weather (power outage fire)
26Behavioral Emergencies
- OSHA cites healthcare facilities under general
duty clause for failure to prevent patient
violence against healthcare workers - Medical providers staff exposed to potentially
dangerous confrontations incl. ill-intended
trespassers - Security audits needed to reveal problems
- Address potential risk of violence
- Source ECRI, HRC Risk Analysis Overview
Managing Risks in Physician Practices, July 2003.
27EQUIPMENT LIABILITYMonitoring to protect against
risk
- THE EQUIPMENT WAS
- appropriate for procedure
- used in reasonable manner (vs. user error)
- inspected for obvious defects prior to use
- on regular preventative maintenance schedule
- All staff using the equipment were adequately
EDUCATED AND TRAINED - Procedures developed staff trained on how to
respond in case of equipment failure
28Environment of CareInfection control Hazardous
Material
- Develop, implement monitor an Infection control
(I.C.) plan pertinent to pt population - Involve I.C. professional
- Protect staff, providers, patients, and visitors
from hazardous material BBP - Trend I.C. events take corrective action
29Risk process 9 Clinic Staff performance
- Staff qualification orientation
- Qualified staff
- Clear, written directives
- Job-tailored Training, initial ongoing
- Human factor remedies distraction, memory
overload, fatigue, confirmation bias - Performance feedback (data based)
- Staffing levels Material resources
30 Accountability Just Culture
- Imperfect behaviors, lapses, oversight
- Inadequate realization of risk, inadequate
diligence systems barriers gaps? - At-risk behaviors -- e.g. shortcuts
- Intentional conduct that unintentionally
increases risk non compliance double check - Reckless behavior
- Recognition of high risk but risk is disregarded
- Intentionally hazardous acts
31Credentialing Focus Initial vs.
Re-credentialing
- INITIAL
Licensure verification,
References re privileges Qualifying education
experience, NPDB ck Provisional credentialing and
Proctoring - RE-CREDENTIALING need Quality Risk data
- Which measures to select how to obtain
- What to do with quality risk information
32Risk process 10 Provider performance, MS
- Quality measures trending
- Service Volume Guideline adherence
- Documentation Prescription review
- Peer Review Risk events
- Adverse outcomes Inadequate processes
- Complaints Disruptive behavior
- Proctoring Provisional Credentialing
33Credentialing Files Risk Quality section
- Credentialing files organized into 2 sections
- Top Confidential, keep secured
- Separate Quality file per practitioner
- Sect. A - Quality data trends
- Guideline adherence MR Documentation
- Sect. B - Risk data events practice pattern
- P.C.E. Potentially compensable event
- Pt. c/o RCA results Peer review reports
34 Medical Record Pertinence Review
- Adequate health history physical exam as
pertinent to pt. presentation complaint - Clinical risk factors IDd on Tx plan
- Conclusions Dx supported by findings
- Diagnostic therapeutic orders supported
- Patient /family involved in Tx plan
- Progress notes indicate continuity of care
- Consulting providers support Tx plan
- Abnormal findings addressed
35California Dept. Managed Health Care (DMHC) Fines
Kaiser Health Plan for Lack of Quality Oversight
(7/07)
- DMHC observed that of 228 peer-review files,
one-third were deficient, such as - Not handling quality concerns promptly
- Not fully considering a physicians complaint
history in evaluating peer-review matters - Not carrying out corrective actions
- HRC Alerts at http//www.ecri.org
36External Peer Review
- Purpose
- Baseline data \proctor role \SE case review
- Contract w/ external qualified physician
- Designate external MD as official member of peer
review committee of requesting facility - A contract protects MD reviewer under HCQIA
- MD reviewer stays anonymous unidentified
- MD may clarify questions re findings, BUT
- External reviewer is adjunct to internal peer
review decision NOT involved w/ investigation