Quality Improvement & Risk Management in the 21st Century

The Rural Health Association of Oklahoma

Fall Conference September 23 – 24, 2010

:Presented by: Jone Friesen

Health Care Compliance Management ResourcesAND

Jason FriesenHealthData Solutions Software

RURAL HOSPITAL QUALITY & RISK MANAGEMENT PROGRAM

Goals: Manageable Simply as possible Relevant/meaningful Meets CMS’s Conditions of Participation Meets Oklahoma State Department of Health

Hospital Standards

MANY NAMES . . . .

“Quality Assurance”

“Risk Management”

“Quality Improvement”

“Quality Assurance Performance Improvement”

FOCUSQuality Patient Care

Patient Safety

THREE PARTS TO A QUALITY AND RISK MANAGEMENT PROGRAM Part 1: Prevention and Reduction of Errors

and Adverse Events

Part 2: Monitoring Effectiveness & Safety of Patient Services

Part 3: Improvement of Quality of Patient Care

THREE PARTS Part 1: Prevention and Reduction of Errors

and Adverse Events• Data collection • Incident reporting

Part 2: Monitoring Effectiveness & Safety of Patient Services• Quality Studies

Part 3: Improvement of Quality of Patient Care• Quality Improvement Organization (QIO)

cooperative projects

PART 1: PREVENTION AND REDUCTION OF ERRORS AND ADVERSE PATIENT EVENTS – USING INCIDENT REPORTING PROCESSES

Collect data on all errors and adverse patient events using electronic system or manually

Investigate incidents & determine the cause of error or adverse event

Take action to prevent future errors or adverse events

Track to determine if the corrective action was successful

PART 1: WHAT DOES THIS PROCESS LOOK LIKE? Collect data on errors & adverse events

Example: Four patient falls Analyze data & determine cause

All four falls occurred as patients were getting out of bed during daylight hours. None of the patients were confused or medicated. Patient’s ages ranged from 35 – 70. Two falls were witnessed, two were not. Each fall occurred within short time after floor had been washed by housekeeping. It was determined all four patients slipped on wet floor as they were getting out of bed.

Take action to prevent more errors or events Patients instructed to not get out of bed unassisted until floor

is dry. If over time, no more errors or events reported

like this one, action was successful.

PART 1: WHO IS RESPONSIBLE? A "Central Person" receives reports of errors

and adverse events Quality Coordinator, Risk Manager, other

designated "Central Person" assigns appropriate staff

person to investigate error or adverse event As appropriate, corrective action is

implemented by person who has authority to do so (example: Department Head)

Results of investigation reported to "Central Person", including what corrective action was implemented

PART 1: THEN WHAT? A "Central Committee" oversees process

QA, QAPI, Risk Management or other named committee Meets at least every quarter The "Central Person" submits reports on errors

and adverse events with corrective actions taken during the past quarter

These reports can be generated using software system or manually

The "Central Person" compares the current quarter reports to past quarter reports to determine if corrective actions were successful in eliminating or decreasing specific errors & events

PART 1: "CENTRAL COMMITTEE" Analyzes reports noting any trends or patterns Ensures that all areas of hospital are involved

in the process Makes suggestions & recommendations for in-

depth Quality Studies of problem prone, high risk or high volume issues.

Ensures that corrective actions decrease or eliminate errors and adverse events.

Minutes of meetings are crucial The "Central Committee" submits reports at

least quarterly to Medical Staff & Hospital Board

PART 1: WHAT IF THE CORRECTIVE ACTION DOESN’T DECREASE OR ELIMINATE ERRORS OR ADVERSE EVENTS? The error and/or adverse event continues

under investigation. The responsible staff members continue to

collaborate & develop solutions to decrease or eliminate the problem.

The "Central Committee" may make recommendations or suggestions.

The "Central Person" continues to monitor to determine if the these solutions or actions are effective.

PART 2: MONITORING EFFECTIVENESS & SAFETY OF PATIENT SERVICES USING QUALITY STUDIES

What is a “Quality Study?” An in-depth study of specific quality or risk

management issue. Needs to be relevant to your hospital May be high volume, high risk, or problem prone

issue How do we determine what to study?

"Central Committee" selects two – three studies at the beginning of each year

Errors or adverse events that are not resolved can be focus of a study.

Recommendations can come from any staff members, the "Central Person", administration, patient or family concerns & etc.

PART 2: HOW DO WE SET UP & CONDUCT A STUDY?

1. Outline the following: The “Central Person” oversees study

Purpose or focus area

Areas or Departments involved

Methodology: (example: Identify contributing factors, obtain input from staff, collect additional data)

Name the persons who will conduct the study or project.

PART 2: HOW DO WE SET UP & CONDUCT A STUDY? (CONT’)2. Conduct the Study or Project

3. Analyze data or results

4. Develop & implement corrective action plan

5. Submit report to the "Central Person", who will submit it to the "Central Committee" for review and input

6. Conduct a follow-up study, to determine if corrective action was effective.

PART 3: IMPROVEMENT OF QUALITY OF PATIENT CAREUSING QIO DATA

Hospital submits required data to QIO (OFMQ) On specific diagnosis

The “Central Person” reviews reports received from QIO or the designated reporting agency.

If standards are not met, the appropriate staff members investigate and follow the process outlined in Part 1.

The “Central Person” submits a report to the “Central Committee.”

SUMMARY

A “Central Person” coordinates the quality & risk management process

The “Central Committee” oversees the entire process

SUMMARYPART 1: PREVENT ERRORS & ADVERSE EVENTS

Collect data on errors and adverse events

Determine cause of error or event

Take action to prevent further errors or adverse events

Did this action take care of problem?

“Central Person” coordinates this process

“Central Committee” oversees this process

SUMMARYPART 2: MONITORING EFFECTIVENESS & SAFETY OF PATIENT SERVICES Conduct Quality Studies

2 – 3 studies per year

More as indicated

An in-depth study of specific quality or risk management issues in your facility

SUMMARYPART 3: IMPROVEMENT OF QUALITY OF PATIENT CARE

Submit required data on patient’s with specific diagnosis

Review reports

Implement corrective action to improve areas not meeting standards

FOUNDATIONAL COMPONENTS: A QUALITY/RISK MANAGEMENT PROGRAM This presentation covers the basic aspects of

a quality improvement program as mandated by CMS & Oklahoma State Department of Health Standards

Implementation of a successful QI program includes using a good software program or manual system to collect data, training staff, setting up the “Central Committee” properly and increasing personnel awareness of importance quality improvement and risk management

Presented by

Health Care Compliance Management Resources

Jone Friesen & Associates LLC 918

445-1576

JASON WITH HEALTHDATA SOLUTIONSPRESENTS:

A System to Streamline: Collecting data on errors and adverse

events

Documenting results of investigations

Generating reports