1. The Rural Health Association of Oklahoma Fall Conference September 23 – 24, 2010 : Presented by: Jone Friesen Health Care Compliance Management Resources AND Jason Friesen HealthData Solutions Software

2. R URAL H OSPITAL Q UALITY & R ISK M ANAGEMENT P ROGRAM Goals: Manageable Simply as possible Relevant/meaningful Meets CMS’s Conditions of Participation Meets Oklahoma State Department of Health Hospital Standards

3. M ANY N AMES.... “Quality Assurance” “Risk Management” “Quality Improvement” “Quality Assurance Performance Improvement”

4. FOCUS Quality Patient Care Patient Safety

5. T HREE P ARTS TO A Q UALITY AND R ISK M ANAGEMENT P ROGRAM 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

6. T HREE P ARTS 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

7. P ART 1: P REVENTION AND REDUCTION OF ERRORS AND ADVERSE PATIENT EVENTS – USING I NCIDENT R EPORTING P ROCESSES 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

8. P ART 1: W HAT DOES T HIS P ROCESS L OOK L IKE ? 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.

9. P ART 1: W HO IS R ESPONSIBLE ? 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

10. P ART 1: T HEN W HAT ? 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

11. P ART 1: "C ENTRAL C OMMITTEE " 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

12. P ART 1: W HAT IF THE C ORRECTIVE A CTION D OESN ’ T D ECREASE OR E LIMINATE ERRORS OR A DVERSE E VENTS ? 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.

13. P ART 2: M ONITORING E FFECTIVENESS & S AFETY OF P ATIENT S ERVICES U SING Q UALITY S TUDIES 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.

14. P ART 2: H OW D O W E S ET U P & C ONDUCT A S TUDY ? 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.

15. P ART 2: H OW D O W E S ET U P & C ONDUCT A S TUDY ? (C ONT ’) 2. Conduct the Study or Project 2. Analyze data or results 2. Develop & implement corrective action plan 3. Submit report to the "Central Person", who will submit it to the "Central Committee" for review and input 4. Conduct a follow-up study, to determine if corrective action was effective.

16. P ART 3: I MPROVEMENT OF Q UALITY OF P ATIENT C ARE U SING QIO D ATA 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.”

17. S UMMARY A “Central Person” coordinates the quality & risk management process The “Central Committee” oversees the entire process

18. S UMMARY P ART 1: P REVENT E RRORS & A DVERSE E VENTS 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

19. S UMMARY P ART 2: M ONITORING E FFECTIVENESS & S AFETY OF P ATIENT S ERVICES 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

20. S UMMARY P ART 3: I MPROVEMENT OF Q UALITY OF P ATIENT C ARE Submit required data on patient’s with specific diagnosis Review reports Implement corrective action to improve areas not meeting standards

21. F OUNDATIONAL C OMPONENTS : A Q UALITY /R ISK M ANAGEMENT P ROGRAM 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

22. Presented by Health Care Compliance Management Resources Jone Friesen & Associates LLC 918 445-1576

23. J ASON WITH H EALTH D ATA S OLUTIONS P RESENTS : A System to Streamline: Collecting data on errors and adverse events Documenting results of investigations Generating reports