pre-claim review demonstration - michigan home …€¢exposure to tb •suicide or attempt •o2...

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©2016 Trinity Health At Home 1

Event Management in Home Health and Hospice

Elizabeth Buckley, RN, BSN, JD, CPHRMIntegrity & Compliance OfficerTrinity Health At Home May, 2017


I do not have any financial relationships to disclose that may cause conflicts of interest in delivering this presentation.

No sponsorship, commercial support, endorsement of any products will occur during this presentation.

Elizabeth Buckley


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1. Terminology of event management

2. Effective event investigation

3. Successful Interviewing

4. Conducting a Root Cause Analysis

5. Action planning and monitoring

Objectives…

©2016 Trinity Health At Home 5©2016 Trinity Health At Home 5

Let’s Start at the Beginning


The hospital just called your clinical manager and let her know that…

At a doctor’s appointment, your home care patient was found to have an wound infection and is sent to the hospital for surgery. Initially it is noted that instead of a daily dressing change as indicated on the 485, he has been leaving his dressing off for 2-3 days at a time and has some missed nursing visits.

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What do you do??


Terminology used in our industry when “things” happen, is very important.

We need to speak a common language when discussing these occurrences with our teams and leadership.

You may hear many terms used to describe and label these things that occur. So let’s talk through some of those terms you have likely heard.

First of all…Use your words…


Sentinel Event: This is a term mainly used by the Joint Commission. The Joint Commission has a list of events, also sometimes referred to as “never events”, that must be handled a certain way.

The Joint Commission list of sentinel events is very hospital focused. Many of these events do not typically occur in the home care and hospice setting, so the use of this term can sometimes be confusing for agencies

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Serious Adverse Event: The Institute for Healthcare Improvement uses this definition: "unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment, or hospitalization, or that results in death.


Serious Reportable Event: This is typically a term used for an occurrence that must be reported either to an accrediting body, a health department, or perhaps even law enforcement.


Serious Safety Event: A term developed by American Society for Healthcare Risk Management to describe a deviation from generally accepted practice or process that reaches the patient and causes serious harm or death

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Near Miss: A near miss is defined as "any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome." (Some studies use the related terms "potential adverse event" and "close call.") In a near miss, an error was committed, but the patient did not experience clinical harm, either through early detection or sheer luck.


Incident: This is typically a term used when referring any event that occurs within the agency or when referring to an incident report. This could describe an event that touches the patient, a near miss, or a process issue.

The most important thing is that everyone on your team knows what each other are referring to and you follow your policy and accrediting standards.


➢ Who is responsible for the investigation

➢ When a root cause analysis is needed and what is it

➢ Time frame for investigation completion

➢ Documentation that your agency requires

Your leadership team should know…

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• Near misses

• Medication errors

• Falls with Injury

• Orders not followed

• EMR errors

• Communication failures

• Equipment failures

What events or occurrences need to be reviewed

• Unexpected Death

• Rehospitalizations

• Untimely admissions

• Exposure to TB

• Suicide or Attempt

• O2 fires


What is your first concern after any event?


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This is always our primary concern once an event occurs involving a patient..

✓ Is the patient safe

✓Have they been transferred to a higher level of care

✓Do they have the correct medications

✓Has the attending physician been notified

✓Does the family need support

✓Does the staff need support

Patient Safety: Are the patient’s immediate needs being met?


Beginning an Event Investigation


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What do you dowhen you say you are investigating….

Record Review

Interview staff involved

Document your findings

WHAT DOES IT MEAN TO INVESTIGATE??


Record Review

Build a narrative of the event and consider the questions below…

What happened? Just the facts ma’am

What normally happens? What would another staff member have done in the same

situation? What does this staff member typically do?

What should have happened? What does you policy/procedure require?

Record Review…


What are you looking for in the record?

▪ Staff involved so they can be interviewed

▪ A timeline or sequence of events

▪ Doctor’s orders pertaining to the wound care

▪ Information on patient education

▪ Visit notes that describe the wound care done

▪ Reasons for missed visits

▪ Physician notification of missed visits

Record Review

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❖Prepare before your interview

❖Diagram your event first to anticipate the questions you will ask

❖Think about asking yourself as you prepare

❖What happened in this case

❖What should have happened

❖What does your policy or process require

❖Consider asking another similar staff member what they would have done

❖Start by asking what happened, in their own words

❖What questions do you have from their response

❖What questions do you have from your record review

❖What “holes” are there in the record

❖What don’t you understand about what happened

Interviewing the staff involved


DOCUMENT YOUR FINDINGS


The purpose of the timeline is to establish a factual foundation of the most pertinent facts, when they occurred and who was involved.

1. Your first box is the starting point, it could be the SOC date or hospital admission

2. Do not try to fit a big narrative paragraph into the box, it is small for a reason

3. This timeline will be verified for accuracy by your record review, interview findings, and your RCA team

4. The timeline will help when your RCA team is reviewing the event to give them a sense of a sequence of events and understand any time-based influences in the event such as shift change, EMR downtime, weekend, etc…

Creating a timeline

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A key aspect of the process is understanding how the various contributing factors relate to each other and ensuring that the analysis has progressed far enough into the blunt end of the system so that root causes can be clearly identified. Diagramming techniques can assist teams to better understand these inter-relationships and ensure a thorough review. Visualization of relationships can help the team see where issues arose and identify areas to target for improvement.*

1. In the first box, enter the adverse event, ie: hospitalization, patient death..

2. In next box to the right, enter why that event occurred, ie: patient fell, patient had an infection

3. Don’t assume you know the answer to why things happened, just insert “why” and gather more information

*CANADIAN ROOT CAUSE ANALYSIS FRAMEWORK; A tool for identifying and addressing the root causes of critical incidents in healthcare

Hoff man, C.; Beard, P.; Greenall, J.; David U; White, J. March, 2006

Creating An Event Diagram


Sharp End vs. Blunt End of the System


Conducting a Root Cause Analysis

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A systematic process to analyze adverse events and near misses. The goal is to identify what happened, why it happened and how to prevent it from recurring in the future. Often multiple causes and corrective actions are identified.

You may have heard of many different tools or approaches to root cause analysis. Some of these are; “The Five Whys”, Learning from Defects, Fishbone diagramming, there are many more…

What is a Root Cause Analysis?


1. What does your agency policy require?

2. Are there any opportunities for improvement in your investigation findings?

3. Did everyone really do what they should have done in this situation?

4. Do your processes or procedures need to be altered based on this?

Do you need to do a Root Cause Analysis?

Example #1: Hospice Patient returns to the hospital from

the assisted living following a fall with head injury. The AL

staff called the on call RN to report the fall the night

before and reported a change in mentation. The on call

RN did not make a visit that night or call the doctor. The

AL staff called EMS. The patient was placed on life support

and died a short time later.

Example #2: Home Care Patient returns to the

hospital following a fall at home with fracture. All

patient and family education re falls is

documented as understood and the PT home

safety assessment with recommendations is

documented. The patient’s wife had made all of

the changes recommended, but patient tried to go

to the bathroom alone and fell.

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Compare example 1 and 2:

Could the fall have been prevented?

Could the staff have managed the situation differently?

Are there opportunities for improvement?

Every event may not need an RCA!

Do you need to do a Root Cause Analysis?


1. Assemble a team, consider including a clinical leader, administrator, staff involved, quality manager, medical director

2. You may also consider inviting people from other departments or agencies who may have been involved such as pharmacy, DME, wound clinic, if your agency allows

3. Schedule two meetings right away so you all have the time set aside on your calendars, many times one meeting is not enough time

4. Create an agenda and follow it

5. Create a packet for your team that includes your timeline, diagram, and any other documents required by your policy

6. Collect the packet back after the meeting so that copies of this confidential information are not floating around

Conducting a Root Cause Analysis


Set some ground rules, you may consider using these…

• ALL TEAM MEMBERS ARE ENCOURAGED TO SPEAK FREELY BUT RESPECTFULLY

• ALL TEAM MEMBERS ARE ENCOURAGED TO SHARE THEIR THOUGHTS AS THE TEAM WORKS TOWARD IMPROVEMENTS.

• IT IS THE ROLE OF THE FACILITATOR TO HELP THE TEAM REMAIN FOCUSED AND TO ENCOURAGE ALL MEMBERS TO PARTICIPATE. IT IS EACH TEAM MEMBER’S RESPONSIBILITY TO BEHAVE RESPECTFULLY AND TO HELP KEEP THE TEAM ON TRACK.

• MEETINGS WILL LAST ONE TO TWO HOURS AND WILL NOT CONTINUE PAST THAT TIME UNLESS EVERYONE AGREES THERE IS MERIT IN CONTINUING.

• THE TEAM WILL RESIST THE TEMPTATION TO “JUMP AHEAD TO FIX THINGS”, UNTIL THE ROOT CAUSE (s) HAVE BEEN DETERMINED, UNLESS THERE ARE URGENT ISSUES THAT NEED TO BE ADDRESSED IMMEDIATELY

Pass them out to the team and read them out loud when beginning the meeting

Conducting a Root Cause Analysis.2

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Use some thought provoking questions, this can help ensure that your team is examining the event from all angles and not jumping to conclusions

• 1. Was PATIENT ASSESSMENT a factor in this event?

• 2. Did STAFF TRAINING OR COMPETENCY ISSUES contribute to this event?

• 3. Was any EQUIPMENT INVOLVED in the event in any way?

• 4. Did the WORK ENVIRONMENT factor into this event in any way?

• 5. Was a LACK OF INFORMATION OR MISINTERPRETATION OF INFORMATION an issue in this event?

• 6. How did COMMUNICATION affect the event?

• 7. Were the APPROPRIATE POLICIES/PROCEDURES, RULES, (OR THE LACK OF), a factor in this event?

• 8. Was there a BARRIER FAILURE; something designed to protect the patient or staff, assure the proper functioning of equipment or control the environment, a factor in this event?

• 9.Were PERSONNEL OR PERSONAL ISSUES a factor in this event?

TRIGGER QUESTIONS Source: VA National Center for Patient Safety

Conducting a Root Cause Analysis.3


Root causes are specific underlying causes. The investigator’s goal should be to identify specific underlying causes. The more specific the investigator can be about why an event occurred, the easier it will be to arrive at recommendations that will prevent recurrence.

Root causes are those that can reasonably be identified. Occurrence investigations must be cost beneficial. It is not practical to keep valuable manpower occupied indefinitely searching for the root causes of occurrences. Structured RCA helps analysts get the most out of the time they have invested in the investigation.

Root Cause Analysis For Beginners by James J. Rooney and Lee N. Vanden Heuvel I JULY 2004 I www.asq.org

Finding the Root Cause(s)


Root causes are those over which management has control. Your team should avoid using general cause classifications such as clinician error, equipment failure or external factor. Such causes are not specific enough to allow management to make effective changes. Management needs to know exactly why a failure occurred before action can be taken to prevent recurrence. We must also identify a root cause that management can influence. Identifying “severe weather” as the root cause of an event is not appropriate. Severe weather is not controlled by management.

Root causes are those for which effective recommendations can be generated. Recommendations should directly address the root causes identified during the investigation. If the analysts arrive at vague recommendations such as, “Improve adherence to written policies and procedures,” then they probably have not found a basic and specific enough cause and need to expend more effort in the analysis process.

Root Cause Analysis For Beginners by James J. Rooney and Lee N. Vanden Heuvel I JULY 2004 I www.asq.org

Finding the Root Cause(s)

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Documenting the findings of your RCA team


Clearly show the cause and effect relationship:

Incorrect: Clinician was fatigued

Correct: Clinician was fatigued because she was scheduled on call overnight for the weekend and was scheduled for 7 visits on Monday, increasing the likelihood that instructions would be missed

Use specific and accurate descriptors for what occurred rather than negative and vague words. Avoid negative descriptors like poor, inadequate, wrong, failed

Incorrect: The manual is poorly written

Correct: The user manual had 8 point font and no illustrations as a result nursing staff rarely used in, increasing the likelihood that the pump would be programmed incorrectly.

Rules of Causation/Writing Causal Statements


Human errors must have a preceding cause

Incorrect: The clinician selected the wrong dose, which led to the patient being overdosed.

Correct: Drugs in the EMR system are presented without sufficient space between the different doses on the screen increasing the likelihood that the wrong dose could be selected which led to the patient being overdosed.

Violations of procedure are not root causes, but must have a preceding cause

Incorrect: the clinician did not follow the procedure for CT scans which led to the wrong name being placed on the CT image

Correct: Confusion in the CT area and pressure to hurry due to several trauma patients waiting for CT on a weekend with only one tech on duty increased the likelihood that steps would be missed.

Rules of Causation / Writing Causal Statements

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Failure to act is only causal where there is a pre-existing duty to act.

Incorrect: The nurse did not make a visit to a patient to draw 8 am labs on Monday.

Correct: The nurse was not assigned to visit this patient on that day because there was no weekend staff assigned to schedule visits for orders taken over the weekend this increased the likelihood of missed visits

Source: RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston: National Patient Safety Foundation, 2015

Rules of Causation / Writing Causal Statements


Now how do we keep this from happening again?


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Goal: To increase system resilience by:

▪ Eliminating the hazard or risk altogether

▪ Mitigating the risk by reducing the severity of effect on the process or to the patient

▪ Increasing the ability to recognize when a risk is present or an error has occurred

▪ Increasing recovery/rescue from an error or an event once it has occurred

Source: The Joint Commission; Not All Action Plans are Created Equal: Developing Strong, Sustainable Action Plans ; Nov. 2016, Buczkowsk, L., Lawler, E., Stein, K. Carter, K.

Effective Action Planning


VA Hierarchy of Actions:

Strong Actions:

1. Do not rely on Human behavior or do not solely rely on memory

2. Attempt to remove human element to the extent possible

3. Makes it difficult if not impossible to do the wrong thing

4. Physical changes rather than procedural

5. Reduce Variation

6. Permanent and sustainable

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Edits on electronic medical record that won’t let you exit

until a field is filled

IV tubing that will not allow you to connect certain types

of piggy backs

Leadership checks in with staff during rounds on how a new

process is going, and follows up if issues are identified


VA Hierarchy of Actions

Intermediate Actions:

1. Support human cognitive and physical limitations by providing back ups

2. Reduce cognitive and physical burden

3. Assist recall, recognition and decision making

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Increase staffing or decrease workload

Software enhancements or modifications

Education using simulations

Checklist or cognitive aids

Standardize communication tools


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VA Hierarchy of Actions

Weak Actions:

1. Rely heavily on one’s ability to remember and apply knowledge, to pay attention, remain vigilant

2. Vulnerable to limitations to memory and attention, fatigue, staff turnover, interruptions, distractions and other common variables in healthcare

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Double Checks

New procedure or policy

Training

Additional study or analysis



❖ Ensure that the entire team is aware of the actions that will be implemented

❖ Do not create the action plan alone in a dark room

❖ Ensure that those responsible for actions know it

❖ No surprises here

❖ One person should be accountable for each action

❖ If everyone is accountable, no one is accountable

❖ Ensure that leadership is on board with the selected actions

❖ Strong leadership buy in can enhance the effectiveness of your plan, no buy in can ruin it

❖ Place monitoring activities in the action plan to maintain compliance, this is typically record reviews or other data collection

❖ Everyone hates this but it is often necessary to make sure the plan is fully implemented

❖ Use dates so everyone is aware of when specific actions will be completed

❖ Revisit your action plan monthly to ensure compliance for at least 90 days, just as you would an accreditation plan of correction

Monitoring for Effectiveness


Your hospice RN case manager arrives to patient home for a visit. There is an ambulance in the driveway. The patient’s daughter is too hysterical to speak. The neighbor tells the RN that the patient has just shot himself and has passed away. He was a 50 yo Army veteran newly wheelchair bound being seen by home care for wound care, he had a massive heart attack last month and had just returned home much weaker. The patients wife had made an appointment last week for a hospice visit. No resumption of care visit was done by home care.

Scenario #2

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QUESTIONS……

pre-claim review demonstration - michigan home …€¢exposure to tb •suicide or attempt •o2...

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