Risk Management Part Two
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Ashley Jairam
Risk Management Program Analysis - Part Two.docx
Summary
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Running head: RISK MANAGEMENT 1
RISK MANAGEMENT 2
Risk Management Program Analysis
Risk management and improvement of quality measures were initiated in Kaiser
Permanente Vallejo Medical Centre (KPV). They were officially put in the procedure and policy
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Prevention of Pressure Injuries at Kaiser Permanente Vallejo Medical Centre
Ashley Jairam
Grand Canyon University
April 28, 2020
format for the prevention of pressure injuries (KAISER PERMANENTE, 2019). The Centers for
Medicare & Medicaid Services (CMS) stated that from October 2008, they were not in a position
to pay for services derived from hospital-acquired conditions (HAC), which incorporated
conditions such as stage III/IV pressure ulcers. As a result, the May 2008 Pressure Ulcer
Prevention and Treatment procedure and policy was put in place. In accordance to the evidence-
based practice and recommendations of the Joint Commission, as well as the participation of the
hospital staff, the policy and procedure was executed on each patient. The summarizes the risk
management policy and process, and it talks about the stakeholders and their responsibilities
towards sustaining the P&P, focusing on the ethical and legal obligations in maintaining it, the
accreditation of the KPV to the Joint Commission as well as demonstrating ways in which these
aspects bring about excellent and quality healthcare.
The Problem and Solution
It is noted that pressure injuries develop as rapidly as two or three hours in cases where
the circulation is cut off to skin mostly at bony prominences. Some of the contributing factors to
pressure injuries include poor nutrition, inability to move, levels of consciousness that are
altered, and failure to walk. All of this can lead to sepsis, infection, osteomyelitis, necrosis, and
even death. (Soban, Hempel, Munjas, Miles, & Rubenstein, 2011).
Apart from the effects that hospital-acquired pressure injuries (HAPI's) have on patients,
KPV observed that it has an adverse impact on the health of the hospital. Statistically, in the
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United States, the average yearly cost of pressure injuries is approximately 9.1 to 11.6 billion,
and in 2018, a single pressure injury cost roughly between 500 and 70000, which is considered
lost funds.
The best prevention measure is policy and procedure (P&P). It incorporates the roles of
nurses, staff, doctors, staff nurses, managers, assistants, and wound care nurses. The act of
prevention encompasses a group of actors. In a case of a patient who scores low on Braden Scale
which is the evidence-based tool representing the risk for HAPI development, will have
measures taken on him/her such as wear special boots to protect the heels, being turned
frequently every two hours and placed cushion sticker on parts such as elbows, upper spine, and
coccyx. Additionally, the patients have frequent skin assessments done every eight hours, as well
as weekly evaluation, which is done by a particular group of nurses who search out for skin
breakdown on the patient. In cases where anything is noted, it is immediately recorded in a chart
to be addressed by the wound nurses and doctor for instruction on care. Essentially, the work of
the Quality department is frequent evaluation for several missed and formed pressure injuries.
The role of the HAPI committee is working towards improving the quality of processes and care.
Joint Commission Role
The main aim of the Joint Commission is to refine our public healthcare constantly. Joint
Commission was founded in 1951 sets a certain standard to meet to be accredited. Accreditation
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Date: 10-Apr-2020
can be described as accessing third party payments and patients. Mainly, if Joint Commission
approves a facility, it means that it meets the standards of not only the JC but also CMS, whose
role is to keep track of whether a facility received federal funding from Medicare and Medicaid.
In regards to, HAPI, JC and CMS have set standards that are in line. JC has set the National
Patient Safety Goals for hospitals which prevent infections by using guidelines to avoid difficult
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to treat infections. Through the Agency for Healthcare Research and Quality, it also provides
resources that assist in risk management and quality improvement. Facilities who want to be
accredited by Joint Commission should pay for membership and have to be surveyed. The
surveyors come in every 36 months unannounced to evaluate the compliance standards, review
medical records, and review data on conditions such as pneumonia and heart attack.
Administrative Roles in Risk Management Strategies
Hospital managers are provided with weekly updates on a number of patients who were
ambulated daily, who got out of bed, HAPPI incidences, among others (Catalyst, 2018). Our
computerized system can track and record these numbers, which will determine how the staff are
doing with pressure injury prevention strategies. The assistant manager, on the other hand, is also
provided with the information and requested to reach out to the staff and encourage them to
handle patients ethically and as required by P&P. The nurses are also required to provide care
and to collaborate with patient care to provide quality care. The Quality department will closely
monitor the PI and liaise with the HAPPI committee to ensure quality care and processes.
Patient Rights and Promotion of Ethical Standards
Tasks and processes at KPV risk management and compliance programs are strictly
guided by the mission and vision statement, which incorporate ethical values. KP asserts that its
main objective is to improve the health status of its members and the community at large. The
organization serves to ensure a positive outcome for patients through care and allow them to
thrive. The statement contains universal ethical principles such as beneficence and fidelity. The
dignity of the patient is maintained at all times whether before operating on them or assessing a
pressure injury.
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Health care practitioners have to follow risk management policies and to practice safe
health care. The staff performs their duties as a nature of health care instead of waiting for the
arrival of JC. Doctors provide the Hippocratic Oath, and nurses and other medical personnel are
taken through ethical training while on the program. The hospital has an ethical review that must
be signed by all staff annually to ensure they comply with its requirement. There is an ethical
committee in place to look into complicated cases of doctors and nurses. Regarding the legal
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side, the committee ensures risk management. The hospital is aware that patients can be hurt;
HAC can occur and can also be sued by the families and patients. Therefore, the safe care of the
patients is a top priority for the hospital right from the start.
Quality Improvement
The quality improvement at the hospital is to promote excellent patient care. Every head
of the department has been trained to determine and implement strategies that will improve the
general quality of the hospital. This will enhance the hospital both for patient care and provide a
safe environment where staff can work. There is a quality department in the organization which
engages other committees to find ways in which nurses can adopt evidence-based practices.
There is a proposal for a committee that will teach evidence-based practices to nurses to improve
their skills.
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References
Catalyst, N. E. J. M. (2018). What Is Risk Management in Healthcare? NEJM Catalyst.
KAISER PERMANENTE. (2019). Pressure injuries: Prevention and treatment. Retrieved from
https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.pressure-
injuries-prevention-and-treatment.abp5591
Soban, L. M., Hempel, S., Munjas, B. A., Miles, J., & Rubenstein, L. V. (2011). Preventing
pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement
interventions. The Joint Commission Journal on Quality and Patient Safety, 37(6), 245-
AP16.
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