Health care risk management assignment week 4

Chapter 8: Patient Safety Tools: Integrating Quality and Managing Risk

Why do we talk about Quality

in the Risk Management setting?

• Risk management makes contributions to

quality by assuring that hazards and

injuries are less likely to occur for both

patients and employees.

• Risk management works to prevent

malpractice claims by identifying,

analyzing and treating risks which quality

assessment tries to eliminate

Predicting Hazards and Malpractice

• Prediction is not specific in risk management – can say an event is likely to occur, but not when or to what extent

• Confounding factor: increased patient satisfaction tends to correlate to lower likelihood of legal action by a patient

• Incident Reporting: can assist the risk manager in identifying causes

Healthcare Acquired Conditions

• Conditions for which, when acquired during admission in the health facility, CMS will not reimburse.

• Examples include: – Foreign object retained after surgery – Air embolism – Blood incompatibility – Pressure ulcer stage III and IV – Falls and trauma – Catheter-associated infection – Manifestations of poor glycemic control

Importance of Communication

• Effective communication is a factor in the likelihood of a patient deciding not to sue a provider as it has impact on patient satisfaction

• Informed Consent is the result of effective communication between the provider and patient. The patient needs to know the possible outcomes of treatment, both good and bad, so as to have proper understanding and expectations.

What if Unanticipated Outcomes Occur?

• Disclosure of unanticipated outcomes is mandatory. The ethical question is NOT should it be disclosed, but how and by whom.

• Risk managers need to plan, prepare and educate staff to avoid inappropriate disclosure

Enterprise Risk Management (ERM)

• An approach to assessing and addressing risks

from all sources that either threaten the

organization’s objectives or represent opportunities

to exploit competitive advantage.

• Categories of Risk – Operational/Clinical Risks

– Financial Risks

– Human Capital Risks

– Strategic Risks

– Legal/regulatory Risks

– Technological Risks

– Natural Disaster/Hazard Risks

Difference from

Traditional Risk Management

• Traditional Risk Management took a more

clinically focused approach and examined

risks individually.

• With ERM, the Risk Manager has a larger

focus and more strategic position. It

begins with risk identification and

determination of the relative importance of

the risk

ERM Process

• ERM utilizes the steps in the traditional

risk management process – Identify and analyze the exposures to loss

– Examine the feasibility of alternative

techniques

– Select the best technique

– Implement the technique

– Monitor and improve the risk management

program

Quality and Risk Management

• Historically Risk Management and Quality initiatives were seen as separate.

• Today, organizations utilize a more integrated approach, recognizing that many risk management errors are breakdowns in process (quality) rather than individual error.

Quality Management Techniques

• Quality Assurance – a formal, systematic

program by which care given to patients is

measured against established criteria.

• Quality Management – encompasses

monitoring and evaluating quality issues,

followed by changes in the system.

Total Quality Management – W. E. Deming

• TQM focuses on the system not the individual – 85/15 rule – 85% of problem is related to

system failure and 15% is the fault of the people involved

• Three premises: – Quality is important and can be measured – People are part of the solution not the

problem – Change is fundamental and can be managed

Quality Management Techniques

• Continuous Quality Improvement (CQI) –

process used to improve their ability to

satisfy customer expectations.

– Directs attention to the fundamental

mechanism that drives a process or system.

– Focuses on techniques to accomplish positive

change by assessing a process that leads to

an intervention.

– Use of sentinel events

Quality Management Techniques

4 Stages for Process Improvement

• Dr. Steven Speer recommends the following states to assist with process improvement: – System design and operation – Problem solving and improvement – Knowledge sharing – Developing high velocity skills in others

Other Quality Tools from Industry

• Lean Management focuses on reducing waste and eliminating error in processes.

• Six Sigma focuses on eliminating causes of defects or error and minimizing variability in process.

Barriers to Quality

Management Initiatives

• Separation of administrative functions – CQI implementation can be difficult as physicians

tend to focus on patients not administrative responsibilities

• Hierarchical and bureaucratic structure makes empowerment difficult

• Lack of recognition of problem-solving initiative

• Lack of vision of the desired outcome

• Inflexible attitude of “this is how it’s always been done”

Quality Improvement Teams

• Quality Improvement Teams (QIT) are change agents.

• Can investigate and recommend improvements, many times in conjunction with the risk manager who may or may not be a member of the team.

Customer is Key

• The quality improvement process views the customer as central to its purpose.

• It is imperative to know who the customer is and their importance to providing care. – Note: the customer is not always the patient.

CQI and Labor Relations

• Risk managers should make sure that any QIT or other CQI program teams are reviewed and deemed allowable by the NLRA. – Some teams may be viewed as labor organizations

dominated by the employer if not structured properly

Determining the Effectiveness of Risk Management

• There is currently no research to definitively demonstrate the effectiveness of risk management programs.

• However, risk management programs are important as adverse events do happen, and there is a need to investigate and implement strategies/improvements to minimize the risk of adverse events recurring.

Program Evaluation

• What are the areas of responsibility or functions defined for risk management?

• Which information or data are collected and available within each of these areas of responsibility or function?

• Can this information or data be categorized and analyzed systematically to derive measures of effectiveness?

Use of Standards

• A standard must be reasonable, achievable and measurable

• Results standards: what is accomplished

• Activity standards: means by which something is accomplished

Evaluation Tools

• Root Cause Analysis

• Failure Mode, Effect and Criticality

Analysis

External Evaluation

• The Joint Commission may evaluate a healthcare organization’s risk management program during the accreditation process.

• Third party payers may also evaluate risk management programs to determine insurability of the organization.

• Benchmarking with other organizations.

Practice Guidelines

• Practice guidelines can set a standard of care to help minimize risk

• May be difficult to monitor

• Risk increases as departure from stated guidelines can be a source of liability

High Exposure Issues

• Clinical Activities

• Monitoring

• Medical Records

• Electronic Health Records

• HIPAA

• Credentialing

• Withholding of Treatment

• Disclosure

Summary

• Quality and Risk Management overlap

• Risk Managers can utilize quality

techniques and reports to assess risk and

recommend improvements