1,40,41,42,43Granada, Yap, Zabala, Zapanta, Young

7/31/2019 1,40,41,42,43Granada, Yap, Zabala, Zapanta, Young

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Introduction

These topics have been assigned to us for one reason and

one reason only: to be presented, and to be presented

not just in any way, but cohesively, comprehensively, and

understandably. These topics are of utmost importance to

be discussed since together they form an integral part ofour profession and the knowledge we will obtain likewise

benefit our clients in the future. Together, they will

eventually form a part of us, and of our colleagues, and

their dissemination among ourselves is simply anopportunity for us to grow, develop, and achieve.


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Objectives

Define quality improvement and discuss the importance

of quality improvement. Identify ways to achieve quality improvement

Discuss the purposes of clinical practice guidelines

Define clinical pathways

Enumerate the differences between audit and research Define utilization review, its importance as well as nurses

roles

Define what is complaints analysis and its importance

Enumerate the the different sentinel events

Define what is morbidity/mortality meetings

Define or describe credentialing and clinical privileging

Discuss variance reporting and analysis


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Quality Improvement

What is Quality Improvement?

To understand Quality Improvement (QI), we must first

understand Quality Assurance (QA). QA is an ongoingsystematic process designed to evaluate and promote

excellence in the service provided to clients. In the health

care setting, QA frequently refers to evaluation of the

level of care provided in an agency, but it may be limitedto the evaluation of the performance of one individual or

more broadly involve the evaluation of the quality of the

care in an agency.


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There are three components of QA:

Structure Evaluation- focuses on the setting in which the

care is given

Process Evaluation- focuses on how the care was given

Outcome Evaluation- focuses on demonstrable changes

in the clients health status as a result of care


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Before a research that leads quality improvement can be

conducted though, the right problem needs to be

identified. As such, the Joint Commission on Accreditation

of Healthcare Organizations has put a great emphasis of

what are called sentinel events. Though this is discussed

in another topic, to simply put, a sentinel event is an

unexpected occurrence involving death or serious injury.They signal the need for an immediate investigation and

response. The findings will improve quality of service.


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What are some ways to achieve quality improvement

Across the board, respondents emphasized that a supportivehospital culture is key to making important advances in qualityimprovement. They identified several key strategies that helpfoster quality improvement, including:

Supportive hospital leadership actively engaged in the work;

Setting expectations for all staffnot just nursesthat qualityis a shared responsibility;

Holding staff accountable for individual roles;

Inspiring and using physicians and nurses to champion efforts;and

Providing ongoing, visible and useful feedback to engage staffeffectively.

While respondents acknowledged these are importantfactors, there was considerable variation in the extent towhich each hospital in the four communities has been able toincorporate these strategies into their individual cultures.


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Leadership Support To create a hospital culture supportive of quality improvement,

respondents stressed the importance of hospital leadership being in thevanguard to engage nurses and other staff. As a representative of anaccrediting organization said, For any quality improvement project to besuccessful, the literature shows that support has to trickle down from thetop. That is important to success. That level of sponsorship has to bethere for quality improvement to be successful. Not only nursingleadership, but across the board from the CEO down.

As an example, the CEO of one hospital supported nurses in their efforts

to better track and address the prevalence of bedsores among patients,even though doing so required that the information be reported to astate agency. Despite the potential for negative attention for thehospital, the CEO encouraged nursing staff to take ownership of a qualityproblem where there was an opportunity to improve patient care.

Hospital respondents expressed the importance of not just paying lipservice to quality improvement, but also to dedicating resources to

these activities. Some hospitals, for example, have reportedly expandedtheir nursing leadership infrastructure in recent years and some havecreated new nursing positions dedicated to quality improvement (e.g.,director of nursing quality). Some respondents reported providing nurseswith more support for administrative tasks such as data collection andanalysis.


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Quality as Everyones Responsibility A hospital culture that espouses quality as everyones responsibility is

reportedly better positioned to achieve significant and sustained

improvement. While hospital respondents characterized the role of

nurses in quality improvement as crucial, they also emphasized thatnursing involvement alone is insufficient because it is not simply

nursings work or qualitys work; it is the work of the whole

organization.

For most hospitals, quality improvement efforts transcend departments,

and nurses are reportedly involved, at some level, in virtually all of theseactivities because of their clinical expertise and responsibility for the day-

to-day coordination of care and other services for patients. To really

improve quality, you have to have every staff member engaged, including

other clinical staff, such as physicians, pharmacists and respiratory

therapists, as well as nonclinical staff, such as food service, housekeeping

and materials management. As a director of quality improvement stated,

Nursing practice occurs in the context of a larger team. Even on a

pressure ulcers team, even though it is primarily a nursing-focused

practice, you have the impact of nutrition, for example. On cases that are

clinically challenging, like transplants, you would also have the impact of

our surgeons, for instance.


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Individual Ownership and Accountability Another key component of a hospital culture conducive to quality improvement

is encouraging individual ownership and accountability for patient safety andquality, according to respondents. In one hospital, for example, there weredelays in notifying physicians of critical lab results. According to the hospitalquality improvement director, when nurses took ownership of the process andstarted collecting the data, they were able to determine the problem andaddress it.

Hospitals have pursued various strategies to increase staff ownership and

accountability. The most commonly reported was to more explicitly include anddetail quality improvement responsibilities in job descriptions and performanceevaluations for staff and in contracts with physicians. Respondents discussedthat this was important for all staff, not just leadership. A hospital CEO stated,We are trying to drive it down further to the nursing staff on the floor, or in theunit, or in the ER, and say, it is part of your job requirements to help us improvepatient care and improve patient satisfaction.

Hospitals also use other types of rewards to encourage staff ownership andaccountability. Respondents discussed a range of ways to reward staff, includingpublic acknowledgement by leadership in staff meetings, writing them thankyou notes, formal award recognition ceremonies and dinners, and sending themto national quality improvement meetings, such as those sponsored by theInstitute for Healthcare Improvement.


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Ongoing Useful Feedback

Hospitals that actively communicate with and provide timely and usefulfeedback to staff reportedly are more likely to foster quality improvement

than those that do not. As one hospital CNO noted, We have tried to be astransparent as we can and share as much information as we can with ournursing staff. They get a lot of information and that helps them staymotivated and engaged in the process.

Hospitals use a variety of feedback mechanisms. One widely used

mechanism is a periodic scorecard that provides information on howperformance, including quality improvement, is progressing toward goals.According to respondents, the information is typically provided at both thehospital and individual unit levels and is visibly displayed throughout thehospital for all staff to see. Other commonly reported methods of providingfeedback on quality improvement include newsletters, staff training, newemployee orientation, e-mail communications, unit-based communication

boards and staff meetings. Respondents cautioned, however, that the keyto effective feedback is not just the amount of information provided, butalso how meaningful that information is for staff. As a hospital CNOexplained, Our quality regimes until now have just been leaning towardgiving numbers. That doesnt affect nurses practice, but if you give themmore detail, it makes it more meaningful for them.


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Two-way feedback between hospital leadership and staff

is also important. Several respondents reported using

patient safety rounds as one way of facilitating this. Inone hospital, executives periodically visit individual

patient care units and sit down and talk with staff. One of

the questions they ask of staff is, What keeps you awake

at night?, referring to any patient quality or safety

concerns staff may have. This process has reportedlybeen effective in identifying areas for improvement, such

as the need for improved response times for the delivery

of supplies and medications to patient care units.


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Clinical Practice Guidelines

The standard definition ofClinical practice guidelines

(CPGs) is that ofField and Lohr [1990]: "systematically

developed statements to assist practitioners and patientdecisions about appropriate health care for specific

circumstances".
http://www.openclinical.org/guidelines.htmlhttp://www.openclinical.org/guidelines.htmlhttp://www.openclinical.org/guidelines.htmlhttp://www.openclinical.org/guidelines.htmlhttp://www.openclinical.org/guidelines.html


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Introduction

Guidelines are designed to support the decision-makingprocesses in patient care. The content of a guideline isbased on a systematic review of clinical evidence - the mainsource for evidence-based care.

The movement towards evidence-based healthcare hasbeen gaining ground quickly over the past few years,motivated by clinicians, politicians and managementconcerned about quality, consistency and costs. CPGs, basedon standardized best practice, have been shown to becapable of supporting improvements in quality and

consistency in healthcare. Many have been developed,though the process is time-and-resource-consuming. Manyhave been disseminated, though largely in the relativelydifficult to use format of narrative text. As yet they have nothad a major impact on medical practice, but theirimportance is growing.


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Purposes of Guidelines

To describe appropriate care based on the best availablescientific evidence and broad consensus;

To reduce inappropriate variation in practice;

To provide a more rational basis for referral; To provide a focus for continuing education;

To promote efficient use of resources;

To Act as focus for quality control, including audit;

To highlight shortcomings of existing literature andsuggest appropriate future research


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Guidelines and Protocols

Clinical protocols can be seen as more specific than

guidelines, defined in greater detail. Protocols provide "a

comprehensive set of rigid criteria outlining the

management steps for a single clinical condition or

aspects of organization".


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Computerized Guidelines

Computerized guidelines encode evidence-basedrecommendations for and can automatically generaterecommendations about what medical procedures to performtailored for an individual patient. Computerized guidelinesoffer benefits over and above those offered by paper-basedguidelines:

They offer a readily accessible reference, providing selectiveaccess to guideline knowledge.

They help reveal errors in the content of a guideline;

They help improve the clarity of a guideline, e.g. in decision

criteria and clinical recommendations; They help offer better descriptions of patient states;

They can automatically propose timely, patient-specificdecision support and reminders


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Clinical Pathways

Clinical Pathways (CP) is multidisciplinary plans of best

clinical practice for specified groups of patients with a

particular diagnosis that aid the co-ordination and

delivery of high quality care. They are both, a tool and a

concept, which embed guidelines, protocols and locally

agreed, evidence-based, patient-centered, best practice,

into everyday use for the individual patient.


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Why Clinical Pathways?

To improve patient care

To maximize the efficient use of resources

To help identify and clarify the clinical processes

To support clinical effectiveness, clinical audit and risk

management


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As Active Management Tools

Eliminate prolonged lengths of stay arising from

inefficiencies, allowing better use of resources

Reduce mistakes, duplication of effort and omissions

Improve the quality of work for service providers

Improve communication with patients as to their expected

course of treatment

Identify problems at the earliest opportunity and correct

these promptly

Facilitate quality management and an outcomes focus


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Four Components of a Clinical Pathway

A Timeline,

Categories of care or activities and their interventions,

Intermediate and long-term outcome criteria,

Variance record


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Guidelines for the Development and

Implementation

Educate and obtain support from physicians and nurse, andestablish a multidisciplinary team.

Identify potential obstacles to implementation.

Use Quality improvement methods and tools.

Determine staff interest and select Clinical Pathways todevelop.

Collect Clinical Pathway data and medical record reviews ofpractice patterns.

Conduct literature review of clinical practice guidelines.

Develop variance analysis system and monitor thecompliance with documentation on Clinical Pathways.

Use a pilot Clinical Pathway for 3 to 6 months; revise asneeded.


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Optimum development and implementation

strategies

Select a Topic

Topic of high-volume, high-costdiagnoses and procedures.

For example:- Critical pathway development forcardiovascular diseases and procedures

Select a Team Active physician participation and leadershipis crucial

Representatives fromall groups

Evaluate the Current Process of Care

Key to understanding

current variation A carefulreview of medical records

Identify the criticalintermediate outcomes, rate-limitingsteps, and high-cost areason which to focus.


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Evaluate Medical Evidence and External Practices

Evaluate the literature to identify evidence of best

practices

In the absence of evidence, comparisonwith other

institutions, or "benchmarking," is the most reasonable

method to use.

Determine the Critical Pathway Format

The format of the pathway includea task-time matrix

spectrum of pathways of the medical record used as a

simplechecklist


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Benefits

Help reduce variations in patient care (by promoting

standardization) Help improve clinical outcomes

Help improve and even reduce patient documentation

Support training

Optimize the management of resources

Can help ensure quality of care and provide a means ofcontinuous quality improvement

Support the implementation of continuous clinical audit inclinical practice

Support the use of guidelines in clinical practice Help empower patients

Help manage clinical risk

Help improve communications between different caresectors


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Limitations of Clinical Pathways

Implementation of the care pathways has not been tested

in a scientific or controlled fashion.

No controlled studyhas shown a critical pathway to

reduce length of stay, decreaseresource use, or improve

patient satisfaction.

Most importantly,no controlled study has shown

improvements in patient outcome


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Potential Problems and Barriers to the

Introduction of Clinical Pathways

May appear to discourage personalized care

Risk increasing litigation

Don't respond well to unexpected changes in a patient's

condition

Suit standard conditions better than unusual or

unpredictable ones

Require commitment from staff and establishment of an

adequate organizational structure

Problems of introduction of new technology

May take time to be accepted in the workplace


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MS Audit

Introduction:

Nursing audit, is a review of the patient record designed to identify,examine, or verify the performance of certain specified aspects ofnursing care by using established criteria.

Nursing audit is the process of collecting information from nursingreports and other documented evidence about patient care andassessing the quality of care by the use of quality assuranceprogrammes.

Nursing audit is a detailed review and evaluation of selected clinicalrecords by qualified professional personnel for evaluating quality ofnursing care.

A concurrent nursing audit is performed during ongoing nursing care.

A retrospective nursing audit is performed after discharge from thecare facility, using the patient's record.


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History of Nursing Audit :

Nursing audit is an evaluation of nursing service. Before1955 very little was known about the concept. It wasintroduced by the industrial concern and the year 1918 wasthe beginning of medical audit.

George Groword, pronounced the term physician for thefirst time medical audit. Ten years later Thomas R PondonMD established a method of medical audit based onprocedures used by financial account. He evaluated themedical care by reviewing the medical records.

First report of Nursing audit of the hospital published in

1955. For the next 15 years, nursing audit is reported fromstudy or record on the last decade. The program is reviewedfrom record nursing plan, nurses notes, patient condition,nursing care.


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Purposes of Nursing Audit

1. Evaluating Nursing care given,

2. Achieves deserved and feasible quality of nursing care,

3. Stimulant to better records,

4. Focuses on care provided and not on care provider,

5. Contributes to research.


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Involves review of records by those

entitled to access them

Requires access by those not

normally entitled to access them

Ethical consent not normally required Must have ethical consent

Results usually not transferable Results may be generalisable

Hypothesis used to generate the

standard

Testable hypothesis generated

Compares performance against thestandard

Presents clear conclusions


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Methods of Nursing Audit

a. Retrospective view

this refers to an in-depth assessment of the quality afterthe patient has been discharged, have the patients chartto the source of data.

b. The concurrent review

this refers to the evaluations conducted on behalf ofpatients who are still undergoing care. It includes

assessing the patient at the bedside in relation to pre-determined criteria, interviewing the staff responsible forthis care and reviewing the patients record and care plan.


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Retrospective audit is a method for evaluating the quality of nursing

care by examining the nursing care as it is reflected in the patient

care records for discharged patients. In this type of audit specific

behaviors are described then they are converted into questions andthe examiner looks for answers in the record. For example the

examiner looks through the patient's records and asks :

a. Was the problem solving process used in planning nursing

care?b. Whether patient data collected in a systematic manner?

c. Was a description of patient's pre-hospital routinesincluded?

d. Laboratory test results used in planning care?

e. Did the nurse perform physical assessment? How wasinformation used?

f. Were nursing diagnosis stated?

g. Did nurse write nursing orders? And so on.


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Method to Develop Criteria :

1. Define patient population.

2. Identify a time framework for measuring outcomes of

care,

3. Identify commonly recurring nursing problems presentedby the defined patient population,

4. State patient outcome criteria,

5. State acceptable degree of goal achievement,

6. Specify the source of information.


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Design and type of tool

Audit as a Tool for Quality Control/Improvement

An audit is a systematic and official examination of a record,

process or account to evaluate performance. Auditing in

health care organization provide managers with a means ofapplying control process to determine the quality of service

rendered. Nursing audit is the process of analyzing data

about the nursing process of patient outcomes to evaluate

the effectiveness of nursing interventions. The audits most

frequently used in quality control include outcome, process

and structure audits.


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1. Outcome audit

Outcomes are the end results of care; the changes in the

patients health status and can be attributed to delivery of

health care services. Outcome audits determine what

results if any occurred as result of specific nursing

intervention for clients. These audits assume the outcome

accurately and demonstrate the quality of care that was

provided. Example of outcomes traditionally used to

measure quality of hospital care include mortality, its

morbidity, and length of hospital stay.


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2. Process audit

Process audits are used to measure the process of care orhow the care was carried out. Process audit is taskoriented and focus on whether or not practice standardsare being fulfilled. These audits assumed that a

relationship exists between the quality of the nurse andquality of care provided.


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3. Structure audit

Structure audit monitors the structure or setting in whichpatient care occurs, such as the finances, nursing service,

medical records and environment. This audit assumes

that a relationship exists between quality care and

appropriate structure. These above audits can occurretrospectively, concurrently and prospectively.


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Utilization Review

What is Utilization Review?

Utilization review consists of examining trends and proposingadvantageous disposition of resources. For example, might clients whohave had a fractured hip repaired have equivalent outcomes at a lessercost if transferred from the hospital to a skilled nursing facility sooner?

Furthermore utilization review is a process implemented by hospitals,insurance companies, and other types of managed care plans. Includedin the utilization review process, is the use of explicit criteria to

determine the medical necessity of the treatment or the health careservice appropriate for such a service. This is critical in order to assure ahealth service meets these stringent and generally acceptedrequirements and is likely to be covered by insurance reimbursement.

Physical status is evaluated against the criteria and a determinationmade as to whether or not a patient requires care at a particular level ofservice, i.e. hospital, in-patient rehabilitation, etc. The criteria used areusually developed by physicians, a review of current evidence andnational guidelines published by specialty organizations.


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There are levels in the utilization review process. The first

level is the initial screening and review of health status

and requested service by a licensed healthcare professional, usually a registered nurse or license social worker

(outpatient therapy). If there is any question regarding

the need for services, the review is passed on to a

physician, who holds active state licensure. That physician

will review all available information, i.e. progress notes,

admission history, lab data, x-rays, etc., and assess the

appropriateness of the care. If the physician determines

that the care needs do not require the health services

being received, he or she will sometimes discuss the carewith the attending physician and determine an agreed

upon treatment plan.


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What is the role of the nurse in utilization review? A utilization review nurse is a registered nurse who reviews

individual medical cases to confirm that they are getting the most

appropriate care. These nursing professionals can work forinsurance companies, determining whether or not care should beapproved in specific situations, and they can also work inhospitals. The goal of members of this profession is to balance theneeds of a patient with the need to reinforce policies, keep costsreasonable, and ensure that patients are provided with medical

treatment which is suited to their situations. Working as a utilization review nurse can be stressful, as it may

involve situations and settings in which nurses are forced to makedecisions which they may not personally agree with. For example,a nurse may feel that on compassionate grounds, a patient shouldhave access to a particular treatment, but that the patient is not

eligible for the treatment, based on the specifics of the patient'scase and the policy of the hospital or insurance company.Members of this profession do need to possess compassion, butthey also need to be able to review situations dispassionately tomake decisions which are fair, even if they may be uncomfortable.

h i l ili i i i i if h
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At a hospital, a utilization review nurse examines patient cases if the

hospital feels that a patient may not be receiving the appropriate

treatment. For example, a doctor might recommend hospitalization, but

the utilization reviewer might feel that the patient does not need to be

hospitalized, and it would be better to discharge the patient to free up abed, save the hospital money, and save money for the patient as well.

Utilization review nurses also review situations like requests for medical

imaging studies, the use of certain medications and treatments, and

recommended medical procedures. Hospital nurses may also be

concerned about whether or not patient cases meet the standards forreimbursement by insurance companies.

In an insurance company, the utilization review nurse inspects claims to

determine whether or not they should be paid. The nurse weighs the

patient's situation against the policy held by the patient, the standards

of the insurance company, and the costs which may be involved intreatment. For example, requests for medications which prolong life are

probably going to be denied if the patient is in hospice care, as hospice

care is designed for end of life treatment. Likewise, if a utilization review

nurse feels that a medication, procedure, or treatment is not medically

indicated, it may be denied.
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To work in this field, it is usually necessary to hold a current

nursing license, and to have experience in the field. Manyutilization review nurses have been nursing for 20 years or

more, and they are familiar with nursing administration,

hospital procedures, and the process of insurance

reimbursement. Job openings are listed in many nursing

trade magazines in addition to public forums. Nurses whoare interested in specialized work such as utilization review

for prisoners or members of the military may need to pass

background checks and fulfill other requirements before

they can start work.
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Complaints AnalysisWhile feedback from customers is to be dealt with in independent

manners, the resolution of the complaint is to be handled by

senior management personnel. It is also a good idea to open anumber of channels for feedback and complaints, such as asuggestion box or nominating an authorized personindependent of production and customer is their entry into thedata base on register of complaints. This is for the followingreasons:

To keep tract of the complaint

To carry out root cause analysis and take corrective actionimmediately so as to eliminate such problems in the future.

To take preventive action.

To find out the lost of poor quality and other statisticalpurposes.

Every complaint should be duly acknowledged. It should bereceive the attention of the top management. The complaintscoordinator cannot be from the customer service or from theproduction or operations to avoid conflict of interest.


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Analyze Independently

The complaint coordinator may designate a team ora person for studying the complaint thoroughly andindependently. The team should study the complaintand verify whether it is true. The team shouldapproach the complaint with an open mind and try

to analyze whether such mistake could haveoccurred in their organization. It should recommendto the top management to take corrective actionimmediately without waiting for the final findings ofthe team. The team should try to have brainstormingsession to find out the root cause of the problems.Therefore they could recommend appropriatesolutions to the top management.


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Complaint recovery process

Each organization has to establish a process for

receiving complaints, processing them,

communicating to costumer and resolving the issue.

This process is aimed at satisfying customers,resolving problems and take preventive actions. The

resolution should satisfy the customer and also the

analysis of the complaint should bring out clearly the

root cause of the problem. The complaints should beranked according to severity and appropriate priority

should be given for resolving them.


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Mortality and morbidity meetings

Definition:

A routine, structured forum for the openexamination and review of cases which haveled to illness or death of a patient, in order to

collectively learn from these events and toimprove patient management and quality ofcare.


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An effective MMR should:

identify key events resulting in adverse patient outcomes

foster open and honest discussion of those events

identify and disseminate information and insights aboutpatient care that are drawn from individual and collectiveexperience

reinforce system level and individual accountability forproviding high quality care

create a forum which supports open and honest discussionthrough the provision of a just, patient centered culture

contribute to clinical governance processes.


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Purpose

MMRs are primarily a tool for examining opportunities forsystem level improvement. The purpose of MMRs is not toassess an individual senior doctors care per se, but toprovide a forum or learning opportunity to assist systemlevel improvement, based around the identification anddiscussion of key issues.

MMRs may provide information to support a greaterunderstanding of clinical practice at the individual seniordoctor or clinical team level, but only when conducted in aconsistent, reproducible fashion within a just culture which

emphasises and supports clinical excellence through opendiscussion of key patient care issues.


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Design Principles for Successful Use of the Tool

MMRs are most valuable as a driver of culture change and clinical

improvement when there is:

a focus on patient care

support and leadership by senior medical staff this ensures

appropriate peer input

and engagement a multidisciplinary approach with input from all staff involved

a consistent and reproducible approach

organizational support

a clear link to organizational clinical governance processes.

a safe and supportive environment

a structured process, including a framework to investigate underlying

contributing factors

a detailed feedback and follow up program.


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An example of a structured process is the Learning from a defect

tool developed to enhance MMRs (Pronovost, Holzmueller &

Martinez 2006). The tool is described as a shorter version of root

cause analysis (RCA) and is intended to improve safety and

teamwork culture, by providing senior doctors with a structured

framework to:

identify what happened with regards to the adverse event determine why the adverse event happened

implement interventions to reduce the probability of its

re-occurrence

enable those involved to evaluate the effectiveness of

those interventions.


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How to undertake MMR meetings

MMRs should be undertaken at a level which ensures that

peer input is appropriate and available. For smallerhospitals this may be at a whole of hospital or even aninterhospital level. For larger hospitals, this may be at thelevel of a clinical service, department or unit. In general,the approach to developing MMR should mirror theorganizational approach to AOS/TCNR, as the AOS/TCNR

program should identify most of the cases to be discussedin a MMR setting.

1. MMRs should occur onsite.

2. MMRs should be chaired by a senior doctor who takesresponsibility for the process and in doing so has anability to engage with clinical colleagues and to facilitatechange at the patient care level. This may be the medicaldirector, unit/department head or delegate.


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3. Where possible, MMRs should be regularly scheduled to

maximise participation.

4. Members of other clinical disciplines and junior medical

staff should attend.

5. Cases for discussion should be identified by:

AOS/TCNR programs

senior doctors raising specific cases referral from other MMR meetings.

6. In order to provide sufficient time for adequate discussion

no more than two cases should be discussed per hour,

although aggregating cases with similar issues into ablock discussion may be appropriate.


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7. Senior doctors and other clinicians actively involved in the

care of the patient to be discussed must be made aware of

the intention to discuss the case at least 72 hours prior to

the case and must be made aware of the date, time and

place of the meeting. If they are unable or unwilling to

attend the meeting where the case is to be discussed, the

case should be referred to the appropriate medical lead for

further investigation or action. Cases must never bediscussed in the absence of the senior doctors with primary

responsibility for care of the patient.

8. Cases should be presented in verbal format in a de-identified

fashion, describing only the facts of the case including any

confounding factors.

9. The major issues should be identified during the

presentation, with the chair providing further clarification if

required.


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10. The chair should ensure that following the presentation, the keydiscussion points are agreed. These should always include:

What went wrong (or right)?

How did it go wrong (or right)? Why did it go wrong (or right)?

What could we do differently in future?

What are the key lessons for the organisation?

11. A consistent approach to problem solving should be used to discussthe case.

12. The chair should ensure that any discussion relates to the facts of thecase and not to personal issues. This is not a meeting to attack oropenly criticise individuals who have contributed to patient caredoing so impedes the development of a just culture.

13. If major performance issues relating to an individual senior doctor

become apparent at any stage during the discussion, the chair shouldimmediately halt the discussion and refer the issue to the relevantmedical lead (medical director, unit head or equivalent), who shouldthen initiate the organisations usual performance developmentprocesses. Discussion around other matters pertaining to the casemay continue.


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14. At the completion of the discussion, action points should

be agreed and prioritised by all present in the meeting.Responses to these issues should be presented at

subsequent meetings.

15. Minutes should be kept patient and doctor details

should be de-identified.16. An action list and appropriate accountabilities should be

generated and circulated to all participants and to

appropriate organisation level clinical governance

structures.

Critical risks to consider in using the tool


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Critical risks to consider in using the tool

MMR meetings should be conducted with a view to enquiry for

the purposes of improvement. They must not be perceived as

being punitive. It must be safe for all participants. The major barrier to effective MMRs is the focus on individual

senior doctor rather than a more general, systems approach to

issues. This results in a fear of incrimination and recrimination.

Significant problems with an individuals clinical care which are

readily apparent to medical leaders should not be dealt with in an

MMR process. Clinical performance issues related to an individual

senior doctor would normally be detected through other

mechanisms (for example, AOS/TCNR, repeated patient

complaints). These issues should be managed using the

Partnering for performance framework in line with the

organisations performance development and support policy.

MMR is not the appropriate forum for this and indeed may be

counterproductive.


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Limitations for MMRs

administrative issues lack of data

procedural concerns includes hindsight andreporting bias, a focus on diagnostic errors,and infrequent occurrence of MMRs

educational issues lack ofeducational/system learning focus.


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Sentinel Events and Monitoring A Sentinel Event is defined by The Joint Commission (TJC) as any

unanticipated event in a healthcare setting resulting in death orserious physical or psychological injury to a patient or patients, not

related to the natural course of the patient's illness. Sentinel events

specifically include loss of a limb or gross motor function, and any

event for which a recurrence would carry a risk of a serious adverse

outcome. Sentinel events are identified under TJC accreditationpolicies to help aid in root cause analysis and to assist in development

of preventative measures. The Joint Commission tracks events in a

database to ensure events are adequately analyzed and undesirable

trends or decreases in performance are caught early and mitigated.

The surveillance of sentinel events which has been well under way inother countries, is an important role of public health. It is an

indispensible tool for the prevention of such events and for the

promotion of patient safety.
http://en.wikipedia.org/wiki/The_Joint_Commissionhttp://en.wikipedia.org/wiki/Root_cause_analysishttp://en.wikipedia.org/wiki/Root_cause_analysishttp://en.wikipedia.org/wiki/The_Joint_Commission


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It is for this reason that the Ministry of Health has

elaborated, with the technical support of Gruppo di

lavoro valutazione degli approcci metodologici in tema di

rischio clinico", this protocol for monitoring sentinel

events with the objective to provide Regions and the

Healthcare Trusts an unambiguous method of

surveillance and management to be applied throughout

the national territory, guaranteeing LEA essential levels ofassistance.

Sentinel Event List


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Sentinel Event List Procedure performed to wrong patient

Surgery performed to wrong part of body (side, organ or part)

Erroneous procedure to correct patient

Instruments or other material retained in surgical site which requiressuccessive interventions or ulterior surgery

Transfusion reaction consequent to ABO incompatibility

Death, coma or severe harm originating from error in pharmacologictherapy

Maternal death or severe illness correlated to labour and/orchildbirth

Death or permanent disability in healthy newborn weighing > 2500

grams not correlated to congenital illness Death or severe bodily harm due to patient fall

Suicide or attempted suicide by patient in hospital

Violence performed on patients


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Acts of violence resulting in injury to healthcare workers

Death or grievous bodily harm consequent to amalfunction with the transport system (intra-hospital and

extra-hospital)

Death or severe injury consequent to the incorrect

attribution of a triage code by emergency servicesdepartment or by (centrale operative 118) emergency

telephone call centre

Sudden death or injury consequent to surgery

All other adverse events that cause death or grievousbodily harm to patient

Credentialing and Privileging


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Credentialing and PrivilegingRationale

The institutes and centers appoint medical staff members (1) to

further their medical or surgical specialty/subspecialty training in aresearch setting or (2) to conduct clinical research after havingcompleted training. For the candidates initial appointment,following nomination for medical staff membership by senior facultyof the NIH institute or center, the Clinical Center follows established

procedures for verifying completion of medical education,postgraduate training, and licensure, and for identification ofpossible adverse occurrences at other institutions.

The nomination process for initial credentialing generally requestsclinical privileges commensurate with the potential medical staff

members training and anticipated Clinical Center activities. Factorsto support credentialing decisionmaking include verification ofcompetence from the applicants prior program director, letters ofrecommendation, and a search, using national databases, foradverse occurrences during previous medical staff appointments.


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Following initial credentialing and awarding of privileges

to a medical staff member, the supervisory senior medical

staff should be vigilant to assure the medical staff

members sustained cognitive and technical competence.

Standard


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Standard

The branch chiefs or section heads of the NIH institutes and centers will

use a Clinical Competency Assessment form to document continued

competence at the time of recredentialing. The practitioners clinical

director must review this form before its submission to the CredentialsCommittee.

Objective data to be considered may include inpatient and outpatient

activity, numbers of procedures performed, complications associated

with procedures, participation in quality assurance meetings,

professional education (including attendance at IC or Clinical Centergrand rounds presentations), and adherence to clinical administrative

requirements (e.g., completion and timeliness of procedure notes,

consult notes, and admission/transfer of service/discharge notes).

If senior staff determine that a medical staff member under

consideration for recredentialing needs monitoring or specialized

training elsewhere, this indication must accompany the request for new

privileges. We encourage supervisory medical staff to review the

Professional Practice Evaluation form with practitioners at intervals

between credentialing cycles because these reviews can be a valuable

mentoring and performance improvement tool

Variance Reporting and Analysis


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Variance Reporting and Analysis Variance analysis is the rubric for comparing actual results with plan

whether budget or rolling forecasts. There are three types:

Traditional variance analysis It works like this: compare actual

amounts at the natural class account level to budget or forecast with a

column that computes the dollar or percentage variance. Alight does this

for all combinations of time periods month, year to date, full year, etc.

Not so traditional variance analysis It should work like this, butusually doesn't: compare actual units, rates and amounts at the line item

level to budget or forecast with columns that compute variances for all

three data types. Alight does this.

Causal analysis Where actual and plan line items include units and

rate as well as dollar amount, you may compute a causal analysisvariance. This variance type calculates how much of the total dollar

variance is due to higher or lower units (the volume impact) or a higher

or lower price/cost (the rate impact). Alight automatically computes

volume and rate impacts for all revenue, expense, headcount and

balance sheet line items that incorporate units and rates.


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Variance analysis reports help quantify and identify thedifference in actual expenditures or revenues between fiscalyears and quarters. In some cases, variance is calculated by

comparing budget to actuals and in others the comparisonis based solely on actuals.

A variance report is a way for business executives to gaugetheir company's performance by comparing one set offigures to another. This usually means comparing a plannedamount to an actual amount.

Companies frequently use variance reports to analyze howclose they've come to hitting forecasted sales targets or tosee if they've met their budgetary goals.

A well-rounded budget variance report will address trends,overspending, and under spending.


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Trends: In challenging economic times, it is important forbusinesses to carefully monitor overspending andunderspending. If there is a trend towards either, then the

entire budget may need to be revisited. A graphic depictionof trends should reveal to the analyst if there are minorbudget lapses or if there is a more serious problem.

Overspending: Overspending: this can pose a serious threat

to the project, to other projects, and to the company ifresources are scarce.

Under Spending: Under spending may indicate a problem inquality control (i.e., the manufacturing process may be

cutting corners) if the project budget was correct at first. Itcan be as serious a problem as overspending.


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Lessons Learned

We have learned the difference between QA and QI, the former

being an evaluation system and quality enforcer, and the latterbeing a problem solver and systems improver.

We have learned that QI is important because it further enhancesthe services rendered to people through meticulous research

We have learned of the various ways to improve the quality in a

health care setting; it is not just an individual role but a collectiveeffort to achieve quality improvement.

We have learned what utilization review is all about: it focuses ontrends and sees which decisions best fit situations.

We have learned that utilization review is important because itprovides the best and fair decisions to clients seeking health care.

We have learned that a nurse assess people in utilization reviewand decides what care/decision be mandated upon them as bestseen in a nurse working for an insurance company.


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We were able to identify the purposes of clinical practiceguidelines.

We were able to define clinical pathways.

We were able to identify the types of variance analysis.

We have enumerated the differences between audit andresearch.

Weve learned that complaints analysis is important inplanning for satisfying the customers. Therefore,organizations should be always receptive to complaints.

Weve learned that morbidity/mortality meetings tend is aroutine, structured forum for the open examination andreview of cases which have led to illness or death of apatient, in order to collectively learn from these events andto improve patient management and quality of care.


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BIBLIOGRAPHY Berman, Snyder, Kozier, Erb. (2008). Fundamentals of Nursing.

Implementing and Evaluating., pp. 239-240

Berman, Snyder, Kozier, Erb. (2008). Fundamentals of Nursing. NursingInformatics. p. 154

Debra A. Draper, Laurie E. Felland, Allison Liebhaber, Lori Melichar. The Roleof Nurses in Hospital Quality Improvement. Washington D.C.; HSCResearch Brief No. 3 : 2008

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