Risk Management: Best Practices to Optimize Prevention

1
Risk Management Best Practices to Optimize
Prevention

• All-Grantee Meeting, Washington D.C.
• June 24, 2008
• Petra S. Berger PhD RN, CPHRM
• Healthcare Quality, Risk Patient Safety
  Consultant
• pberger_at_rmpsi.com - Phone [phone]

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 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 

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VITAL BRIDGE OVER TROUBLED WATERS

• QUALITY MANAGEMENT
• Patient Safety Q. I. Risk
  Management identify risk respond
  prevent

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DIVERSE QUALITY RISK GOALS on O N E
Platform

• Efficiency Cost control
• Access to care Referral mgt
• Patient Satisfaction
• Clinical Effectiveness
• Regulatory compliance
• Patient Safety vs. error, delay, omission

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PURPOSE x 3 RISK MANAGEMENT

• STOP PREVENT HARM
• Patient Advocacy
• PROTECT the Healthcare facility from
• litigation and financial loss
• patient and community distrust
• PROTECT involved Providers Staff

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Health Center Trends and Issues

• Claims Occurrence
• Error in Diagnosis 30
• Treatment related 21
• Medication related 10
• OB Related 22
• Surgical Procedures 6
• Claims Location
• Health Center 65
• Hospital 35

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Liability Analysis Allegation of NEGLIGENCE

• Duty based on existing provider-patient
  relationship
• To exercise degree of care that a reasonable
• competent provider would exercise under same
• or similar circumstances
• Breach of Duty
• Plaintiff must show that defendant failed to
  exercise
• reasonable care, and adherence to
• established clinical standards (expert testimony)
• Injury proximately CAUSED by breach (foreseeable)

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Case Example Medication Monitoring

• 58-year-old male patient is scheduled for a major
  diagnostic procedure at the hospital where a
  certified registered nurse anesthetist (CRNA)
  provides conscious sedation.
• A required copy of the clinic medical record is
  sent preoperatively. No mention is made of the
  patients seizure medication.

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Case 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.

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Liability Analysis Duty? Breach? Injury?
Damages?

• A. Standard of Care - prelude to Q. measures
• Monitoring patient medication document
• Test result reported to signed off by provider
• Patient notified documented
• Treatment plan updated, w/ or w/out change
• Medical records accurate comprehensive
• B. CRNA hospital standards of care

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PRIMARY STRATEGY OF RISK CONTROL Risk
Identification Analysis

• Event or Claims review Root Cause analysis
• Incident reporting - adverse event (1 - 30)
• Omitted or delayed diagnostic workup
• Adverse medication event
• Patient or family complaint or feedback
• Staff feedback surveys
• Risk reporting marathons snapshots
• Occurrence Screens
• Missed appointments Waiting times

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Risk process 1 Patient communication

• Patient assessment interview
• Treatment planning Goal contracting
• Non compliance Termination of care
• Informed Consent / refusal
• Health instruction literacy interpreters
• Explain back / read back
• Patient feedback complaints

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Informed Consent or refusal

• Used whenever an invasive procedure is proposed
  that carries a risk of harm
• Medical Provider has discussion of the
• Procedure and benefits (P)
• Risks of the procedure ( R)
• Alternatives to the procedure (A)
• Questions asked (Q)
• What should be documented?
• Consent process, any questions answered

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Complaints Regulatory requirements

• CMS CoP - Infraction of patient rights IF
• Evidence of non responsiveness
• Non-resolution of complaint or grievance
• Complaint verbal, informal, promptly resolved
• Grievance req. investigation 7d TAT appeal
• Develop 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

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Complaints Preventive factors

• Organizational Factors
• Culture of Patient centeredness
• Certain care processes that invite complaint
• Medical Provider Staff Factors
• Communication skills Clinical skills
• Time pressure, fatigue, frustration
• Patient Factors
• Difficulty understanding feeling abandoned
• Stress of diagnosis, finance, grief, fear
• Somatizing non adherence

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Disclosure What and How

• Known Facts s/p investigation
• Same as documentation, medical record
• SUMMARY Sequence of events
• SUMMARY Discovered Cause(s) per evidence
• Clinical results effects on patient
• Corrective actions taken no staff names
• Empathy concern expressed to patient
• Apology if error made and harm caused

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Risk Process 2 Organizational Provider
Communication

• Flow Availability of Organizational Information
  (P P, Staff Educ., Pt. Info., MR)
• Inter-provider team relations conflict mgmt
• Communication breakdowns occur during hand-off at
  transition points from one provider to another --
  verbal written
• Communication barriers are cause of 2/3 of
  serious medical errors (JC reports)

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Risk process 3 Litigation review
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

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Risk process 4 Clinic Operations (systems)

• Continuum of care (62 claims) F. U.
• vs. Fragmentation across settings
• Referral management
• Diagnostic test tracking
• After hours coverage Telephone triage
• Access to care No shows
• Missed Appointments
• Tickler system, patient return for annual exams,
  FU tests, preventive screens

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Risk process 5 Clinical Practice

• Medical evaluation Treatment
• Complex medical conditions Cancer, Co-morb.
• Medication therapy Pre-natal risk factors
• Pre- and post-surgical patient evaluation
• Use of Practice Guidelines decr. variability
• Asthma, Anticoagulants, Stroke, Pediatric Fever
• Guarding against Complications (preventable)
• OB, Surgical procedures, Emergency
• Sample protocols can be accessed at
  http//www.guideline.gov/

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Risk Outcome 6 Diagnostic Error, Delay,
Oversight

• Most frequent
• Cancer Myocardial infarction Stroke
  Meningitis Acute abdomen Fractures Prenatal
  risk factors Infections post surgical
• Factors
• Atypical signs symptoms
• Incomplete or inaccurate information about
  medical history many co-morbidities
• Insufficient diagnostic work up Delays

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Confirmation Bias

• Paris in the
• the Spring
• Once we decide that we know what something
  is, we tend to exclude or neglect information
  that may be contrary to our original perceptions

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Diagnostic Test tracking per Flowchart
Checklist

• Test ordered by med. provider log
• Request form created - copy retained
• Test completed - patient compliance?
• Results received and logged in / ck log
• Results reported to provider (same day for
  abnormal /critical value results)
• Patient notification documented

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Risk process 7 Medication Safety

• Adverse Medication events related to phases
• Product labeling, packaging, nomenclature
• Prescribing Indications, interaction, off label
• Antibiotics, anticoagulants, narcotics,
  cardiovascular, steroids
• Dispensing compounding, distribution error
• Administration wrong drug/ dose/ route
• Source National Coordinating Council on
  Medication Error Reporting and Prevention
  www.nccmerp.org

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Risk process 8 EQUIPMENT EOC EMERGENCY
RESPONSE

• Emergency protocols implemented and monitored for
• Medical emergency
• 1 BLS trained staff on-site at all times
• Crash cart (incl. pediatrics) checks
• Behavioral emergency
• Building /weather (power outage fire)

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Behavioral Emergencies

• OSHA cites healthcare facilities under general
  duty clause for failure to prevent patient
  violence against healthcare workers
• Medical providers staff exposed to potentially
  dangerous confrontations incl. ill-intended
  trespassers
• Security audits needed to reveal problems
• Address potential risk of violence
• Source ECRI, HRC Risk Analysis Overview
  Managing Risks in Physician Practices, July 2003.

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EQUIPMENT 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

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Environment 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

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Risk process 9 Clinic Staff performance

• Staff qualification orientation
• Qualified staff
• Clear, written directives
• Job-tailored Training, initial ongoing
• Human factor remedies distraction, memory
  overload, fatigue, confirmation bias
• Performance feedback (data based)
• Staffing levels Material resources

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Accountability Just Culture

• Imperfect behaviors, lapses, oversight
• Inadequate realization of risk, inadequate
  diligence systems barriers gaps?
• At-risk behaviors -- e.g. shortcuts
• Intentional conduct that unintentionally
  increases risk non compliance double check
• Reckless behavior
• Recognition of high risk but risk is disregarded
• Intentionally hazardous acts

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Credentialing Focus Initial vs.
Re-credentialing

• INITIAL
  Licensure verification,
  References re privileges Qualifying education
  experience, NPDB ck Provisional credentialing and
  Proctoring
• RE-CREDENTIALING need Quality Risk data
• Which measures to select how to obtain
• What to do with quality risk information

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Risk process 10 Provider performance, MS

• Quality measures trending
• Service Volume Guideline adherence
• Documentation Prescription review
• Peer Review Risk events
• Adverse outcomes Inadequate processes
• Complaints Disruptive behavior
• Proctoring Provisional Credentialing

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Credentialing Files Risk Quality section

• Credentialing files organized into 2 sections
• Top Confidential, keep secured
• Separate Quality file per practitioner
• Sect. A - Quality data trends
  
• Guideline adherence MR Documentation
• Sect. B - Risk data events practice pattern
• P.C.E. Potentially compensable event
• Pt. c/o RCA results Peer review reports

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Medical Record Pertinence Review

• Adequate health history physical exam as
  pertinent to pt. presentation complaint
• Clinical risk factors 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

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California Dept. Managed Health Care (DMHC) Fines
Kaiser Health Plan for Lack of Quality Oversight
(7/07)

• DMHC observed that of 228 peer-review files,
  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

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External Peer Review

• Purpose
• Baseline data \proctor role \SE case review
• Contract w/ external qualified physician
• Designate external MD as official member of peer
  review committee of requesting facility
• A contract protects MD reviewer under HCQIA
• MD reviewer stays anonymous unidentified
• MD may clarify questions re findings, BUT
• External reviewer is adjunct to internal peer
  review decision NOT involved w/ investigation