2016 Federal Tort Claims Act (FTCA) Risk Management ......on the Clinical Risk Management Program website. All resources are provided for FREE by ECRI Institute on behalf of HRSA.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Addressing Disruptive Provider Behavior in a Culture of Safety Learning Objectives
Introduce concepts of a culture of safety State the proactive ways that can be used to avoid disruptive behavior Clearly outline what to do and how to manage an identified behavior issue Discuss the concepts of conflict resolution and managing violence in the workplace
Identifying and Preventing Behaviors that Endanger Patient Safety
Fundamental components of a culture of safety include teamwork across disciplines and the ability to discuss safety issues in a blame-free environment. When a health center identifies red flag issues related to provider or staff behavior (e.g., patient complaint about inappropriate conduct, employee report of disruptive behavior, suspected drug diversion), it should take immediate action to address that complaint or behavior.
Behaviors such as intimidation, sexual harassment, and drug diversion undermine a culture of safety. They may contribute to patient harm, undermine staff morale, result in resignation by qualified employees, fuel malpractice suits, and injure the organization’s reputation.
Health centers and free clinics can refer to the checklist and resources below for guidance in addressing disruptive, inappropriate, and unprofessional provider or staff behavior.
Establish a culture of safety within the health center and free clinic and be certain that staff are able to identify and react to inappropriate or disruptive behavior (see the Safety Climate Survey and the Agency for Healthcare Research and Quality’s [AHRQ] Safety Culture and example and article on setting the standard for professional behavior).
Develop a code of conduct that defines disruptive or inappropriate behavior (harassment, sexual misconduct, offensive behavior, inappropriate relationships). Policies and procedures should complement the code of conduct and outline specific processes for addressing violations. The Joint Commission recommends a “zero tolerance” approach to any behaviors that undermine a culture of safety (see the Joint Commission’s Sentinel Event Alerts on Behaviors that Undermine a Culture of Safety and Leadership Committed to Safety).
Develop procedures and practices for investigating all complaints of inappropriate or disruptive behavior and formalize appropriate standardized corrective actions.
Train all personnel about staff-patient boundaries, chaperone use, and staff members’ responsibility to immediately report all concerns related to sexual or behavioral misconduct to designated leadership.
Provide training to managers on conflict resolution and collaborative practice techniques. Coaching and mentoring are ways to implement interventions and
address behaviors (see the AHRQ patient safety primer on Disruptive and Unprofessional Behavior).
Ensure that evaluations and assessments of professional competence include evaluation of interpersonal activities and skills. Disruptive behavior can be fueled by a high-stress environment; increased productivity demands; failure to address unprofessional conduct; a lack of interpersonal, coping, or conflict management skills; intense emotions; personal problems; or substance abuse. Address these triggers as appropriate.
Maintain a confidential reporting system where employees can report confirmed or suspected instances of inappropriate or disruptive behavior including controlled substance diversion. Protect employees from retaliation for reporting or identifying inappropriate behaviors (see also the Event Reporting Toolkit).
Alert staff to drug diversion behaviors, encourage that staff use “see something, say something” protocols, and encourage prompt reporting internally and to appropriate agencies (see also CDC’s Risk of Healthcare-Associated Infections from Drug Diversion and Nurse Drug Diversion and Nursing Leaders' Responsibilities).
Make staff aware of the possible consequences associated with drug diversion, including providing substandard patient care; loss of license, credentials, or employment; litigation; imprisonment; and potentially loss of life.
Put systems in place to guard against prescription drug theft and diversion, and ensure compliance with protocols (see DEA’s Office of Drug Diversion Rx Abuse Online Reporting and Investigations of Employee Behavior).
Make pharmacists aware that they have a corresponding responsibility to prescribers to identify red flags and comply with state pharmacy board regulations (see Red Flags-Warning Signs-Rx Diversion).
Want to learn more? Refer to the guidance articles Disruptive Practitioner Behavior and Human Resources and the sample policy Professional Office Standards for Employees on the Clinical Risk Management Program website. All resources are provided for FREE by ECRI Institute on behalf of HRSA. Don't have access or want to attend a free, live demonstration of the website? E-mail [email protected] or call (610) 825-6000 ext. 5200.
Information provided by ECRI Institute is intended as guidance to be used consistent with the internal needs of your organization. This information is not to be viewed as required by ECRI Institute or the Health Resources and Services Administration.
that is unwarranted and is reasonably interpreted by a reasonably prudent person under similar circumstances to
be demeaning or offensive.” Persistent, repeated inappropriate behavior should be treated as “disruptive behavior.”
(AMA)
Bullying behavior, behavior that is demeaning to other healthcare practitioners, and
berating other providers in the presence of patients or their families is another
manifestation of disruptive behavior. Workplace bullying involves repeated health-
harming mistreatment usually directed toward underlings or peers, and it affects the
quality of patient care (Halverson). Workplace bullying falls into one or more of the
following categories: work sabotage, verbal abuse, or conduct that is threatening,
intimidating, or humiliating. Workplace bullying can occur among all levels of staff,
and healthcare organizations should adopt a zero-tolerance policy for such behavior.
The concepts of power and authority in the healthcare hierarchy may play a role as possible causes of disruptive
behaviors. Although women are increasingly taking on positions of authority in healthcare organizations, gender-
based power relationships continue to exist in the healthcare environment. (MacDonald)
Perceptions of how an organization deals with disruptive behavior also differ somewhat by gender. According to a
2011 report, female respondents to an American College of Physician Executives survey were overall less confident
than their male counterparts about how their organizations deal with disruptive behavior. Compared with the male
respondents, nearly twice as many female respondents strongly disagreed that their organization has a clear, well-
enforced policy on disruptive behavior. More than a quarter of male respondents strongly agreed that there was a
structured method to report incidences of disruptive behavior, but only 17% of females answered similarly.
(MacDonald) For more information about the survey, see “Web Resources.”
Barriers to Addressing Disruptive BehaviorOrganizational reluctance to confront practitioner disruptive behavior may be rooted in the following organizational
factors (Rosenstein):
Cultural inertia
History of tolerance
Code of silence
Fear of antagonistic physician reaction
Organizational hierarchy
Conflicts of interest
Lack of organizational commitment
Ineffective structure or policies
Inadequate intervention skills
Tips for Confronting Disruptive BehaviorImplementing four basic steps can help organizations effectively confront disruptive practitioner behavior: (1)
develop and distribute a written code of conduct for all staff members, (2) develop a written policy that defines
behaviors that are unacceptable, (3) implement a nonretaliatory reporting system, and (4) educate all staff about
the code of conduct, policy, and confidential disruptive-behavior reporting system and the facility’s policy of
nonretaliation for reporting in good faith.
Because of the wide range of behaviors that constitute disruptive behavior, healthcare organizations should ensure
that its code of professional behavior states a clear and comprehensive definition of disruptive behavior. The
definition of disruptive should include behaviors (including repeated behaviors) that should be referred for
How to Use Credentialing and Privileging to Improve Patient Safety Learning Objectives
Recognize the purposes credentialing, privileging, and renewal of credentials and privileges
Explore how credentialing can identify potential red flags before a provider practices in a health center
Understand how performance reviews and clinical competence assessments performed during renewal of credentials and privileges can identify potential quality and safety concerns
Apply principles of credentialing, privileging, and renewal of credentials and privileges to the case scenario
Privileging is the process that health care organizations employ to authorize practitioners to provide specific services to their patients (see: HRSA’s PIN 2002-22). Assessing clinical competence is an integral part of the privileging process; it assures that providers and staff possess the requisite skills and expertise to manage and treat patients and that they are able to perform the medical procedures required to provide authorized services within the scope of project.
Proper assessment of clinical competence is a critical step in providing safe patient care and in mitigating risk. Health centers and free clinics can use the following checklist and the links to tools as guidance in assessing clinical competence of providers. For more information see: Get Safe! Effective Processes for Granting Clinical Privileges.
Establish a procedure for assessing clinical competence (to include health status), ensuring that competence is evaluated by staff aware of the skills and knowledge required by each job.
Assess clinical competencies based on the area of practice (available resources such as: Adult-Gerontology Primary Care Nurse Practitioner Competencies; Competencies for the Physician Assistant Profession; Federation of State Medical Boards Clinical Competence Assessment Resources) and assure that providers meet the standards of practice and training that allow them to manage and treat patients with a level of proficiency that minimizes the risk of causing harm.
Utilize peer review and/or performance improvement data for privileging and re-privileging providers.
Adopt appropriate tools (such as: Medical Assistant Skills Checklist, Peer Review Checklist, National Health Policy Forum Physician Assessment: Measuring Competence and Performance) and proctoring procedures for continual assessment of clinical competence.
Educate staff about the credentialing and privileging process and about core clinical competencies for their area of practice (i.e. Implementing the ACGME General Competencies Requirements).
As part of the health center’s quality improvement efforts, establish, implement, and routinely review policies and procedures for evaluating and regularly re-
evaluating clinical competencies (see: Developing Policies and Procedures Toolkit on the Clinical Risk Management program website).
Establish an appeals process for licensed independent practitioners in the event that a decision is made to discontinue or deny clinical privileges.
Want to learn more? Refer to the Credentialing Toolkit, Initial Privileging Process Flowchart, Renewal of Credentials and Privileges Flowchart, and the webinar: Developing and Maintaining an Effective Credentialing and Privileging Program on the Clinical Risk Management program website. All resources are provided for FREE by ECRI Institute on behalf of HRSA. Don't have access or want to attend a free, live demonstration of the website? E-mail [email protected] or call (610) 825-6000 ext. 5200.
Information provided by ECRI Institute is intended as guidance to be used consistent with the internal needs of your organization. This information is not to be viewed as required by ECRI Institute or the Health Resources and Services Administration.
Instructions: Complete this checklist when conducting medical record review or direct observation of a licensed
independent practitioner. Please see below for the key for scores A, B, and C.
Score A: Care provided at a level expected of an experienced and competent practitioner managing the patient’s care within the practitioner’s scope of practice
and in a similar manner as the practitioner.
Score B: Care provided at a level expected of an experienced and competent practitioner managing the patient’s care within the practitioner’s scope of practice,
and whose care might differ somewhat from the care provided, but within accepted standards.
Score C: Care that differs from what an experienced and competent practitioner, managing the patient’s care within the practitioner’s scope of practice, would
have provided with reference to clinical/professional guidelines, peer reviewed literature, standards of care, and/or compliance with health center policy.
SCORE the following issues A B C Comments
Assessment/diagnosis
History/physical examination
Technique/skills (if observed)
Communication with other providers/patient
Patient education
Treatment plan
Plan is prioritized by chief complaint, history, physical
examination
Appropriate diagnostic tests are ordered and addressed
Appropriate medications are ordered
Page 2 of 3
Proprietary and Confidential
Copyright ECRI Institute, 2013
Appropriate non-pharmacologic treatments are identified
Consultation/Referral
Follow-up
Documentation
Legibility/ use of EHR
Completion
Dates and signatures
States healthcare goals and outcomes
Compliance with health center policy and procedures
Adverse event/Adverse outcome/Near miss
Briefly describe:
Supervision – adheres to protocol agreement or other written arrangement
OTHER quality/safety issue: State the issue and briefly describe the basis for
the reviewer’s concern:
________________________________________
________________________________________
System or process problem identified. Circle Yes or No
If yes, briefly state the problem identified:
Adapted from: Georgia Department of Community Health – Division of Public Health Quality Assurance/Quality Improvement for
Public Health Nursing Practice. Quality assurance/quality improvement for public health nursing practice manual: standards and tools
[online]. 2010 Dec [cited 2013 Feb 8]. Available from Internet at: http://health.state.ga.us/pdfs/nursing/QA-QIManual/Tab%204-
All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and nonmember
institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials. Healthcare laws, standards, and
requirements change at a rapid pace, and thus, the sample policies may not meet current requirements. ECRI Institute urges all members to consult with
their legal counsel regarding the adequacy of policies, procedures, and forms.
Adverse Event Analysis: A Staff Training Exercise Learning Objectives
Understand the steps of event analysis Recognize how to gather information about an event Recognize how to conduct interviews Understand how to create a timeline of an event Learn how to analyze data related to an event Identify root cause and contributing factors of an event
Using EHRs to Coordinate Care for Complex Patients
Caring for complex patients demands intensive monitoring, tracking, and coordination to ensure maximum patient safety and the best achievable health outcomes. Providers must identify and incorporate all pertinent medical and non-medical factors in their treatment plans. These factors may include a history of frequent admissions and readmissions to hospitals or other healthcare settings, a behavioral health or substance abuse diagnosis, multiple co-morbidities, limited access to services provided outside of the health center, multiple prescriptions, difficult social situations, and hazardous physical environments. Electronic health records (EHRs) are valuable tools that can help providers monitor and follow up on complex patients’ multiple healthcare needs as well as exchange information with other providers and specialists.
The following checklist and resources can help health centers and free clinics use EHRs to manage complex patients both within the clinic and across the continuum of care. Additional information appears in Get Safe: Managing Complex Patients across the Continuum of Care and Get Safe: Ensuring Care Coordination of the Medically Complex Patient.
Maximize the use of the patient problem list in the EHR. The problem list provides a centralized location where all providers in a health center or free clinic can view a summary of the patient’s status.
Maximize the use of the medication list in the EHR. Reconcile medication lists frequently for medically complex patients and instruct patients to bring medications with them to appointments so the provider can carefully review and document brands, dosages, and frequencies of all current medications. (For more information, see the guidance article Medication Safety.)
Set up reminders in the EHR for diagnostic tests (e.g., repeat bloodwork, imaging studies) so the care coordinator can follow up to ensure that this testing is completed in a timely manner. (For more information, see the Office of the National Coordinator for Health Information Technology’s SAFER Guide: Test Results Reporting and Follow-Up.)
Consider enhancing the EHR to include electronic exchange of clinical information between providers. Ensure that policies are in place that clearly assign responsibilities for accessing, reviewing, and acting on findings in EHRs. (For more information, see case studies from HealthIT.gov.)
Consider measuring key areas related to care coordination of complex patients as part of the health center’s or free clinic’s quality improvement/quality assurance activities. For example, set a metric related to how often complex patients need to be seen by their primary care provider (e.g., every three to four months) and measure the health center’s progress toward this goal. (For more information, see the Agency for Healthcare Research and Quality’s Care Coordination Measures Atlas and the archived webinar The Use of EHRs for Quality Improvement.)
Be aware of Medicare and Medicaid incentive programs for meaningful use of certified EHR technology, including incentives for using EHRs for care coordination functions (additional information is available from HealthIT.gov).
Want to learn more? Refer to the guidance article Medical Records and the archived webinar Electronic Health Records: Emerging Risks on the Clinical Risk Management Program website. All Clinical Risk Management Program resources are provided for FREE by ECRI Institute on behalf of HRSA. Don't have access or want to attend a free, live demonstration of the website? E-mail [email protected] or call (610) 825-6000 ext. 5200.
Information provided by ECRI Institute is intended as guidance to be used consistent with the internal needs of your organization. This information is not to be viewed as required by ECRI Institute or the Health Resources and Services Administration.
Continuous Quality Improvement: Learning from Events Learning Objectives
Develop corrective actions that are linked to identified root causes Develop corrective actions that are effective and impactful Develop measures of effectiveness for corrective actions
Data-driven quality improvement (QI) measures are an essential part of improving patient outcomes, managing population health, reducing cost, and increasing the satisfaction of patients and staff. Quality measures focus on structures or processes of care related to positive health outcomes that can be facilitated by the health center or free clinic. Gathering data on measures that are important to the health center and that are valid, feasible, reliable, predictable, and evidence-based will facilitate improved health outcomes for patients.
Health centers and free clinics can use the following checklist and resources to help identify opportunities to use data-driven quality improvement initiatives in their facility.
Recognize the benefit of the data gathered and the role of data in identifying high-risk populations, supporting evidence-based medicine, and improving processes. (See also the National Quality Forum’s ABCs of Measurement.)
Ensure leadership support and commitment for data-driven quality activities. For more information, refer to The Healthcare Executive's Role in Ensuring Quality and Patient Safety.
Set organization-wide, as well as project- or care-level, quality goals and measures. See the HHS Measures Inventory on the Agency for Healthcare Research and Quality (AHRQ) website.
Assemble the appropriate team to champion the measure and develop strong team skills by using tools such as TeamSTEPPS.
Recognize that electronic health records (EHRs) are just one form of technology that allows data to be readily accessed and utilized. Remain cautious of using data from health information exchanges, mobile devices, and personal fitness monitors because these data may require additional steps to standardize before use.
Ensure that the data gathered is the appropriate measure for that health outcome. As an example refer to AHRQ’s Child Healthcare Quality Toolbox which includes Understanding Quality Measurement.
Establish good data governance and a high-quality data warehouse recognizing the difference between static data (such as date of birth) and dynamic data (such as glucose levels), as well as when data maintenance occurs and what version of the
EHR is being used. For more information refer to the American Health Information Management Association’s (AHIMA’s) Data Quality Management Model (Updated).
Use a deliberate and defined improvement process such as Plan-Do-Check-Act (PDCA)/PDSA: Plan-Do-Study-Act (Rapid Cycle Improvement).
Recognize and celebrate successful initiatives and implement them on a larger scale.
Continue to evaluate and monitor initiatives in order to maintain improvement.
Want to learn more? You can learn more about Performance Management & Measurement and obtain help in developing and measuring quality improvement goals by reviewing Managing Data for Performance Improvement.
Additionally you can refer to the QI/QA Plan: Meeting to Facilitate QI/QA Activities from the 2014 Virtual Conference, Data-Driven Quality Improvement, and The Use of EHRs for Quality Improvement in the Webinar Archive, as well as tools and policies in the Quality Improvement/Quality Assurance Toolkit, all available on the Clinical Risk Management Program website. All resources are provided for FREE by ECRI Institute on behalf of HRSA. Don't have access or want to attend a free, live demonstration of the website? E-mail [email protected] or call (610) 825-6000 ext. 5200.
Information provided by ECRI Institute is intended as guidance to be used consistent with the internal needs of your organization. This information is not to be viewed as required by ECRI Institute or the Health Resources and Services Administration.
Using Valid Quality Improvement (QI) Methodologies
Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient groups. Quality initiatives in health centers and free clinics can transform the delivery of primary care services and facilitate the triple aim of improved patient experience, improved population health, and reduced costs. An effective QI strategy must incorporate QI methodologies that are tailored to QI activities in the practice. Health centers and free clinics can use the following checklist and resources to help identify and select the QI methodologies that are best suited for their quality activities.
Ensure leadership support and commitment for the QI/QA plan and related activities. Be certain to include quality updates as part of the board’s agenda.
Use a deliberate and defined improvement process such as Plan-Do-Check-Act (PDCA) / PDSA: Plan-Do-Study-Act (Rapid Cycle Improvement).
Set organizationwide as well as project- or care-level quality improvement goals.
Establish quality initiatives in your facility in response to such things as community need, performance of a process over time, or performance of daily health center activities. Refer to suggestions offered in the “Potential Quality Indicators” slides in the handouts for ECRI Institute’s 2014 Virtual Conference presentation, QI/QA Plan: Meeting to Facilitate QI/QA Activities.
Establish a team to set quality initiatives for the year involving key leaders and staff. Refer to Building Quality Improvement Capacity in Primary Care for more information on team approaches to quality activities.
Identify issues for quality analysis and establish a baseline. Develop actions and tasks, prioritizing as you move forward, set benchmarks and targets, develop project plans, implement plans, and monitor outcomes by using data. For more information refer to Performance Management & Measurement.
Use tools such as flow charts, cause and effect diagrams (Fishbone diagrams), Pareto charts, checklists/check sheets, histograms, and scatter diagrams to support QI/QA activities.
Identify triggers (issues/concerns) for a root cause analysis. Use root cause analysis tools to examine the potential root cause of an issue. Identify risk
assessments to focus on by using tools such as the root cause rating form. For an example of an issue for root cause analysis and the steps of the process refer to Root Cause Analysis Workbook for Community/Ambulatory Pharmacy.
Want to learn more? Compare the relationships among various quality improvement tools, learn the Basics of Quality Improvement in Healthcare, and develop Tools and Strategies for Quality Improvement and Patient Safety. You may want to also consider whether a Quality Improvement Strategy | Safety Net Medical Home Initiative is helpful for your health center or free clinic.
Additionally you can refer to the QI/QA Plan: Meeting to Facilitate QI/QA Activities from the 2014 Virtual Conference, The Use of EHRs for Quality Improvement in the Webinar and Audio Conference Archive, tools and policies in the Quality Improvement/Quality Assurance Toolkit, and previous Get Safe! communications such as Improving Provider-Patient Communication and Maintaining Continuous Quality Improvement, all available on the Clinical Risk Management Program website. All resources are provided for FREE by ECRI Institute on behalf of HRSA. Don't have access or want to attend a free, live demonstration of the website? E-mail [email protected] or call (610) 825-6000 ext. 5200.
Information provided by ECRI Institute is intended as guidance to be used consistent with the internal needs of your organization. This information is not to be viewed as required by ECRI Institute or the Health Resources and Services Administration.