10/5/2016 1 Clinical Practice Guardrails: Role of QA and Documentation in Patient Care Jonathan W Gietzen MS PA-C Department of Family Medicine Kaiser Permanente Hillsboro, OR Lecture goals Understand the role and process of Quality Assurance Committee Review common clinical reasoning errors Review common charting tips to strengthen patient care and reduce risk for error Disclosure: I have no conflict of interest in relation to the content presented in this lecture. Qualifications Nearly 33 years in ICU/hospital, home health, primary health care Care provider, shift lead, manager, educator, administrator, researcher, published author Kaiser Permanente Regional Adult Primary Care Quality Assurance Committee Kaiser Permanente Systems and Safety Committee Two QA investigations into my practice as a PA in 18 years.
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10/5/2016
1
Clinical Practice Guardrails: Role of QA and Documentation
in Patient Care
Jonathan W Gietzen MS PA-C
Department of Family Medicine
Kaiser Permanente
Hillsboro, OR
Lecture goals
� Understand the role and process of Quality Assurance Committee
� Review common clinical reasoning errors
� Review common charting tips to strengthen patient care and reduce risk for error
� Disclosure: I have no conflict of interest in relation to the content presented in this lecture.
Qualifications
� Nearly 33 years in ICU/hospital, home health, primary health care
� Care provider, shift lead, manager, educator, administrator, researcher, published author
� Kaiser Permanente Regional Adult Primary Care Quality Assurance Committee
� Kaiser Permanente Systems and Safety Committee
� Two QA investigations into my practice as a PA in 18 years.
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QA Process
� The peer review process is a mechanism to evaluate potential quality of care concerns to determine whether standards of care are met and to identify opportunities forimprovement. The process is used to monitor and facilitate improvement at the individual practitioner and system levels to assure safe and effective care. (KPNW)
� The QA process is;
� Not punitive
� A mechanism to reduce
� Near misses,
� Misses &
� Sad outcomes
Scoring
�P0/S0 care is acceptable
�P1/S1 Minor/moderate opportunity for improvement
�P2/S2 Significant opportunity for improvement and/or care deemed inappropriate
Quality Care Wall
0 brick= P0, 1 brick = P1,
2 or more bricks = P2
Appropriate Technical Expertise or Consultation
Adhered to Evidence Based Guidelines
Correct and Timely Tests and
Therapy
Effective Communication
Adequate Documentation
Suggested Defense: Routinize each behavior for each basic encounter you perform
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Doing Same Thing = Same Results
Suggested Defense: Rule of Three
Substitution Test Algorithm
Evaluate for possible system
errors
Does not Merit peer review =Done
Merit peer review, if YES, Review possible
system and documentation
issues
Within standard of care? Done
Not within Standard of Care
Pass Substitution Test?= Yes
Clinical Risk Low = P1 Clinical Risk High = P2
Pass Substitution Test? = No
Clinical Risk Low= P1
Clinical Risk High = P2
Suggested Defense: Ladies and Gentlemen of the Jury
Your Response To QA Inquiry
�To do
�Check with supervising MD/Mentor
� Timely response
�Don’t hold back, be honest
�Avoid
�Cagey responses
�Not answering the questions asked
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Your Response To QA Inquiry
�QA is not punitive, However You can get in trouble when; �A clear pattern of behavior has
been identified which puts the patients and organization at risk from this clinician
�Given opportunities to improve and then not show improvement
� E.g. LAMISIL in someone with Fatty liver and chronically elevated LFT
Common Clinical Traps: RESPECT
� Sedatives, (Anything that can increase risk for fall (muscle relaxer, anxiolytic, etc.)
� Flexeril in elderly, they fall and earn a C-4
� Pain medications. Opioids OD in younger pts, give smaller quantities, check psych history), limit long term, long acting opioids in the young, check for pts receiving meds from
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Common Clinical Traps: RESPECT
� Elderly, poly pharmacy, decreased ability to metabolize, multiple side effects, multiple co-morbids.
� Coumadin (interacts with everything, check INR when adding a med, notify ACC team when adding a med)
Common Clinical Traps: RESPECT
� Testosterone
� Secondary hypogonadism
� Screen questions may help identify a more likely cause for their desire to seek testosterone (OSA, obesity, MJ use)
� Rigid onboarding criteria
� Rigid monitoring due to multiple side effects
� Recommend involve endocrinology
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Testosterone Screening Questions
�Prior testosterone, iron, BMI, UDS
�Recent severe acute illness
�Loss of androgen-dependent body hair or change in shaving pattern
�Testicular atrophy
�Hx Testicular trauma or torsion
Testosterone Screening Questions
�Gynecomastia/breast development
�Marijuana Use
�Hx of Mumps orchitis
�Chemotherapy, radiation therapy
�Change in PERIPHERAL visual field?
�New headaches?
Testosterone Screening Questions
�Elevated iron levels?
�Problem with sense of smell?
�Untreated sleep apnea?
�Sleep disruption, shift work?
�Chronic narcotic use?
�Has ever fathered a child?
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Common Clinical Traps
� Poorly differentiated dx is a higher risk patient than almost any other pt.
� The sickest patient is the one without a diagnosis. Wacksman
� Common things are common
� It is more common to see an uncommon presentation of a common condition, than to see a common presentation of an uncommon diagnosis.
Common Clinical Traps
�“The patient can have as many diagnosis as they !@#$% well please.” Hickam’s Dictum.
Common Clinical Traps
�THREE plus a ZEBRA helps clearmind and focus on the encounter
� Include a realistic differential diagnosis in most notes
� If ‘hot potato’ include why or why not the diagnosis does not fit
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Common Clinical Traps
�Patients presentation does not fit with their CC
� Progressive LBP, now in w/c,
�Revisit diagnosis
�Ask for help, avoid lone wolf disease.
Common Clinical Traps
�“If you understand physiology, you can always pick the right answer” RiffatMorgan MD
Documentation Pearls
� Address CC even if CC per pt is incorrect (pt reports no SOB despite that being listed as their CC today)
� Look at any problem list, add things to problem list even if temporary
� Take credit for work you do
� If you interpret an x-ray, say so
� If you spoke to a colleague about case, document it
� If you and pt agreed to a plan that was non-standard, say so.
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Documentation Pearls
� If you cut and paste from other notes or sources
� You are responsible for that information in the note.
�Comment on this information
� Reference where information from (e.g. CareEverywhere, x-ray report, lab report, etc) include date.
Documentation Pearls
� Vital sign review and comment
� I comment on every VS for every patient.
� Look at trends, look at the graphics or tables.
� Examine the part complained of;
� Usually the system above and below, or
� All parts included in that body part (e.g. wrist would be skin, nerve, vascular, tendon, bone, muscle)
� If not improved on this plan in 2-3 days, would CONSIDER….
Anticipatory Guidance
�Anticipate what questions may have about their condition. Address them up front;
� Reduces call backs
� Reduces repeat visits
� Reduces request for additional testing
� Reduces request for referral
� Increases pt confidence in your skills/dx
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Anticipatory Guidance
�Examples
� If you do prescribe it, make sure there are parameters on when to return, when to stop.
�Not unusual for a patient tx’d for pneumonia to have a more productive cough once infection clears. Explaining this will often save a call or clinic visit.
Anticipatory Guidance
�Pt sprains ankle, 3 days later had bruising into their foot
� Give advice bruising can happen due to gravity they are less likely to come back in
� If you fail to mention it, then they think you missed something
� They won’t trust the original evaluation
� May want additional testing or referral
Anticipatory Guidance
� Put in next step if pt does not improve
� Return for recheck if not improved in 2-3 days
� Call back in 2 days…
� If worsening or develop new or other concerning symptoms, be seen sooner
� If you feel your symptoms are significantly worse, go to ED
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Anticipatory Guidance
�Document why varying from care
� If patient declines, document this, (and/or order test anyway to show that you knew what next step was)
� If making a palliative care decision include discussion in your note (include who is in the room as well, if possible their names and relationship to pt)
Anticipatory Guidance
� If your plan is close follow up
� Make sure they get an appt scheduled,
� Have a back up plan if worse between now and the future appt
� If significant concern, you send a tickler to yourself to call pt or remind pt if they do not come to the fu appt
�At every point, try to close the loop where pt care may suffer
Lecture goals
� Understand the role and process of Quality Assurance Committee
� Review common clinical reasoning errors
� Review common charting tips to strengthen patient care and reduce risk for error