Utilization & Risk Management PDF

PERFORMANCE MANAGEMENT AND PROCESS IMPROVEMENT Chapter 3-Part 2 Mohamed Eldeeb CPHQ,CPHRM,LSSBB,TQM,SCRUM Master ,TOT , Team STEPPS master training QUALITY, RISK, UTILIZATION, AND PATIENT SAFETY PLANS :  Written plans generally descri...

PERFORMANCE MANAGEMENT AND PROCESS IMPROVEMENT Chapter 3-Part 2 Mohamed Eldeeb CPHQ,CPHRM,LSSBB,TQM,SCRUM Master ,TOT , Team STEPPS master training QUALITY, RISK, UTILIZATION, AND PATIENT SAFETY PLANS :  Written plans generally describe quality management / improvement, utilization review/ management, risk management, patient safety functions, and govern their operations.  The plans may be separate or integrated. All plans should align with the organization's vision and strategic goals.  All organization wide plans related to the provision of patient care and services must be approved by  Utilization Management:  Technique used by the payer of health care to manage costs through analysis of medical necessity and appropriateness of care including the appropriateness of: Managem 1. Admission ent of 2. Treatment and investigation resource 3. LOS 4. Discharge needs HIGH QUALITY + COST EFFECTIVE.  Utilization Management Plan :  To ensure that the healthcare organization provides medically necessary at the appropriate level of care while optimizing quality outcomes and financial performance.  To ensure effective and efficient utilization of hospital facilities and services and includes a performance improvement component. (CPGs)  Utilization Management generally is described in writing because it is an organization-wide process with many component steps.   Utilization Review Inpatient Out patient Admission criteria Encounter/visit Treatment & investigation Treatment & investigation necessity (resources) necessity (resources) Length of stay Accessibility of service Transition of care Multiple encounter / revisits Discharge criteria Referral Readmission Revisit  Utilization Problems Under Over Misutilization utilization utilization In efficient use of resources. Abuse the hospital Underuse of service resources without even with evidences of necessity. medical necessity. 1. Admission without Wrongly use of hospital necessity resource. 1. No order of ttt. 2. Overuse of antibiotic 1. Wrong ttt. 2. No investigation 3. Increase LOS without done necessity 3. No care coordination 4. Abuse for (consultation) investigation   How to prevent utilization problem? Pre 1.Pre-authorization process in MCO approv al (managed care organization. 2.Assessment of data or cases by Peer physician advisor , medical director review with subsequent dialogue with primary care practitioners. Action 3.QI team activities to improve systems and processes associated with inefficient delivery of care.  Managed care Organization:  Responsible for both delivery and financing of health care service.  Establish links among provider, patient and payer  Both patient and provider have an agreements with MCO: 1. Patient agrees for payments of the services. MCO 2. Provider agree to accept the fees offered by Patie Provid MCO. nt er  Effective Utilization management 1- Top level commitment. 2- Recognition that utilization management is a part. of overall quality management. 3-Knowledge of current laws. 4- effective UM plan.(SMART) 5-Coordination with all care levels and care management. 6- Effective communication and education systems. 7- Computerized databases and information systems for tracking UM data with comprehensive reporting  Care Coordination: It is a function that helps ensure that patient’s needs for health services are met and information sharing across people ,functions and sites are met over time. Coordination maximizes the value of service delivered to patients by facilitating beneficial ,efficient ,safe and high quality services and improving health outcome. It involves management of delivery of wellness , disease and chronic care services to both individual client ( case management) and selected populations (population management). Care coordination assumes there is a patient care management system in place which link patient needs to available services.  How does Care Coordinator work? 1.Proactive care plan and follow up 2. Communication: information availability and shared decision making 3. Information systems: easily accessible by practitioner 4.Transition/hand off between staff. SBAR: Structured Communication tool designed to convey a great deal of information to be transferred accurately between HCW.  CASE MANAGEMENT  It is the clinical and administrative coordination of all phases of patient care, where specific clinical outcomes are achieved within a time frame.  The case management process consists of intake and assessment, treatme development of a care plan, case coordination, discharge nt plan planning, and quality management. Measura Intake and assessment begins with admission to particular ble goal service. A comprehensive care plan is developed after the initial Educati assessment. on  The plan of care should contain: 1-A treatment plan established by the healthcare practitioner in  Role of case treatme manager? nt plan 1. Ensure that only medically appropriate and cost Case progres conscious care is provided to patients. sion 2. Maintains an overview of the case and helps the Assess primary care provider maintain an objective needs Pt. ongoing assessment of the patient’s educatio healthcare needs. n Discharg 3. Responsible for ensuring continuity of care e plan from  Community of case management = Care 1. coordinator Healthcare delivery model developed by healthcare providers for community based population of patients with chronic conditions requiring intervention to help prevent emergency visits or hospitalization. 2. Nurse and practitioners home visits and follow up visits ,communication with primary care and specialist physician. 3. It’s a team approach involving the nurse , practitioner , hospital social services , case management based on patients needs. 4. Patients are candidate if they meet one or more of the following criteria:  Care Coordinator Case Management Ongoing in the community level Triggered by hospitalisation (focused (prevent decline in patient health before on safely discharging the patient they happen) Community based (Family based) Patient based Build relationship between the team and Working to link the care team to create patient care to identify the risk and.comprehensive care plan.prevent it  POPULATION MANAGEMENT 1. Case management rightfully focuses on the individual patient. Shared 2. The concept of population management is a newer capitati epidemiological on focus on groups of patients with certain conditions. ‫مبلغ ثابت‬ 3. We will focus on: ‫بيتم االتفاق‬ Disease Management ‫عليه‬  Disease Demand Management programs. management: 1. Generally refers to the management of populations of patients with high risk, high cost, high volume, high maintenance chronic disorders across the continuum of care. 2. It is intended to help patients reach better outcomes and reduce  Component of full service disease management program: 1.Population identification. (selection criteria) 2.CPGs 3.Plan of care (potential/proactive) 4.Risk assessment 5.Patient & family education/behavior change 6.Outcome measurement and evaluation  Demand It is management: the use of decision support system to influence the Acces patients 'decisions about : Improve s 1. whether ,when , where and how to access medical services. connection 2. Demand management incorporates tele-service between technologies ,triage. operation 3. The managed care organization’s use of a 24-hour nurse-staffed Opand market i telephone hotline to inform member/patient callers of care of tio c at ca n E du n options and provide self management education. re Track o pt. Components of the Demand management support system: conditi on Call center or hotline 24hrs. staffed with RNs(referral nurse) who use protocols or clinical algorithms approved by physicians to inform callers about care options.  Risk Management:  is the process of identifying, assessing and controlling threats to an organization's capital and earnings. These threats, or risks, could stem from a wide variety of sources, including financial uncertainty, legal liabilities, strategic management errors, accidents and natural disasters.  Respond to the chance of: 1. increasing incidence. of medical- legal issues. 2. control the financial costs. 3. diminish the emotional costs to family, society, the physician and health care insurance. That is why the process of Risk Management (RM) was devised. Risk Management in a healthcare setting seeks to anticipate, respond to, control,  The role of the Risk Manager: Risk The 1. Identify and manage risk possibility 2. Prevent and minimize risk of harm of loss or (Patient,Visitor,HCW) injury. 3. Identify opportunity of improvement Management 4. Reduce (not eliminate financial loss). The act or art of conducting or  control liability, prevent or reduce supervising financial loss, and protect the something financial assets of the organization.  Effective Risk Management Programs emphasize "harm prevention" for patients, visitors, and staff more than financial loss.  day-to-day responsibilities of the Risk Manager include: dealing with incident report investigations. patient complaints. litigious situations. adverse patient events or outcomes. conducting root cause analysis. proactively assessing risk to the organization(FMEA).  Regardless of the type of healthcare organization, the Risk Management Plan should be developed by the executive and Risk Management leadership and must be approved by the organization's governing body. The  Traditional and Enterprise risk management Traditional Enterprise risk Retrospective action proactive action management risk Focus on hazard Focus on the potentiality Segmental ( local Holistic approach Multi dimensional approach ) One dimensional assessment (S-D-O) Non insurable risk assessment (S) insurable  Risk Management Program Components: Loss prevention and reduction (clinical and administrative components) Claims management Safety/security programs Patient relations programs Contract and insurance premium review Employee programs/workers compensation Resource and support system review Linkage with quality, patient safety, and utilization  Enterprise Risk management: the process of identifying, assessing and controlling threats to an organization's capital and earnings. Risk domains: 1.Operational 2.Clinical & Patient Safety. 3.Strategic. 4.Financial. 5.Human Capital. 6.Legal & Regulatory. 7.Technological. 8.Environmental- and Infrastructure-Based Component of ERM: Step :s 1. Identify risk 2. Analyze risk 3. Evaluate risk 4. Treat risk 5. Monitor Risk Identification :The first step in loss prevention and reduction is the identification of risks in the organization are. These risks can be clinical risks or non- clinical/administration risks. The risk management program must contain processes for the identification of potential risks and implementation of steps to avoid or reduce the risk of adverse occurrences or claim and/or to Risk Identification : MEA = F Proactive RCA = Reactive  How do we identify the risk (source of risks identification.) Continuous measurement and data collection through: Occurrence screening – Incident report (early warning system)  External review data – patient satisfaction – physician referrals – observations – safety committee. Review of : litigation cases in which medical records are requested or identified bylaw or literature review). Continuous analysis of key exposure areas to identify risks: Professional malpractice General liability for injuries to patients , visitors  Example for : Professio Negligenc nal e liability 1. Lack of proper care 1. Wrong diagnosis --- 2. Basis on Improper TTT. malpractice 2. TTT out side field of 3. Reasonable competency care based on a (privellidge) defined 3. Abandonment standard 4. No informed consent 4. Mal practice 5. No investigation judged by peer 6. No result of the test review  Organization wide early warning system:  An organization wide system to screen all patients for real or potential adverse incidents, issues, and occurrences that might result in increased risk to the organization or corporation and/or less than optimal quality of care. To identify as early as possible all: 1. Adverse Events 2. Potentially compensable event. Adverse Patient Occurrence (APO): An unexpected, untoward event with actual or potential negative impact on the patient, or person. Potentially Compensable Event (PCE): An APO that might result in a lawsuit or claim based on the degree of actual or potential impact on the patient.  In most healthcare organizations, the risk manager has been given a list of PCEs that the facilities insurance company wants to be notified about if they should occur.  The insurance company then examines the record and makes a determination if the event truly is a potentially compensable event. If it is, then the medical record and  In case of claim:  The staff should be aware that if an adverse event occurs and there is equipment involved, it should be taken out of services and sent to the Risk manager's office. This would include any equipment, medications, syringes and supplies in use at the time of the event. If this is not accomplished at the time of the event, it is too late to sequester these items. If later it is determined that the event was not a PCE, these items can be discarded as appropriate, or placed back into the inventory for use.  The Risk Manager must sign legal papers indicating this when the records are sent to attorneys during a lawsuit. If the medical records are on paper, the record of the visit where the event occurred should be copied.  In case of claim:  If someone wants to add a late entry to the record, the individual should be escorted to a private room, and the escort should remain in the room after giving the individual the original record, an appropriate form to write on and a pen.  The individual must date, time and sign the entry, as well as indicate that it is a late entry.  The individual is not allowed to remove or cross out anything in the record.  If the medical records are electronic, the Information Management department should make the record read only once the patient is discharged following the event.  In case of claim: Equipment sequester/Isolation Medical record kept under locked and key in RM office Copy place back to MRD For late entry staff should be escorted in room & sign for late entry Not allow to remove or cross out in Medical record EMR will be in read only mode  IHI Global Trigger Tool:  Developed by IHI , uses consistent retrospective random review of patient records and a list of triggers to track three measures:  Adverse events per 1,000 patient days: Total# adverse events/ Total Length Of Stay (LOS) for all records reviewed X 1,000  Adverse events per 100 admissions: Total# adverse events/ Total records reviewed X 100  Percent of admissions with an adverse Trigger s "clues" or “generic screens” to guide trained reviewers with clinical backgrounds (usually nurses) to review the information in the patient's record that may be confirmed by a physician as an adverse event. Examples: include any code or arrest, patient fall, transfer to higher level of care, change in surgical procedure, readmission within 30 days, Harm unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that  results Harmin death CATEGORIES: Category E: Temporary harm to the patient and required intervention Category F: Temporary harm to the patient and required initial/prolonged hospitalization Category G: Permanent patient harm Category H: Intervention required to sustain life Category I: Patient death  Organization wide early warning  system: Generic screening: Concurrently screen every patient hospitalization, ambulatory service or home care An example of 100% review process  Incidents reporting: Notification of adverse patient occurrence & PCE  Patient safety data screen: NAHQ survey Risk Assessment:  Risk analysis  Risk Evaluation 2-Risk Analysis:  Once potential risks are identified, they must be analyzed in order to determine their significance.  A tool that is commonly utilized when an adverse event occurs is a Root Cause Analysis (RCA).  If potential for risk is identified, then a Failure Mode Effectiveness Analysis FMEA should be used to identify the risk and attempt to eliminate the risk before an adverse event occurs. 3-Risk evaluation: Time of risk ranking Process of prioritize the potential risk RPN=S*F 1. Who will score the risk? 2. How we will calculate it? 4-Risk treat: The process of selecting and implementing of  There measuresare four main risk to modify risk. management 1. Risk strategies, or risk treatment options: acceptance. 2. Risk transference. 3. Risk avoidance. Reduce Avoid 1.Risk4.acceptance Risk Frequency : reduction. A risk is accepted with no action taken to mitigate it. Accept Transfer Impact 2.Risk transfer (shifting): A risk is transferred via a contract to an external party who will assume the risk on an organisation’s behalf. 3.Risk avoidance: A risk is eliminated by not taking any action that would mean the risk could occur. 4.Risk reduction/prevention: A risk becomes less severe through actions taken to prevent or minimise its impact. Risk monitoring: The process of tracking and evaluating the level of residual risk Simply after implementing our action plan (our treatment option) again we will assess the risk score expecting decreasing the score but if it is still high we will analyse the risk again and change our strategy or our action plan to manage it. Risk assessment reflects the power of the frontline understanding the processes in their unit will and how it affect on the organization and reflects also system thinking for the leader in the organization.  Role of GB in ERM? 1. Support implementation of risk management program. 2. Establish firm polices to minimize risks. 3. Ensure the compliance to laws and regulations. 4. To oversee the processes supporting public reporting of adverse events. 5. Support all to Obtain proper consent for medical care. 6. Know and monitor the area of organizational risks( FMEA results). Infection Prevention and Control:  The Infection Preventionist:  Should be aware of, and prepared for, a global outbreak such as there was with Ebola.  Concerned with the transmission of disease and safety, the underlying function is patient/employee safety, decreased morbidity and mortality of infectious pathogens, and decreasing institutional costs relating to nosocomial infections. The primary recipient of this concern is no longer just the patient, but also the staff and visitors to the healthcare organization.  There must be policies and processes implemented to mitigate the risk of  The Infection Preventionist's role Identify : patient infections and to assure that the patient and others are doing all they can to prevent the spread of that infection. The Infection Preventionist is also responsible for employee health in many organizations. Ongoing review and analysis of healthcare-associated infection data (based on the organization-approved definition), risk factors and special studies for infection prevention and  The Infection Preventionist control. processes: Identification through cross-contamination of surveillance data and case finding analysis of data investigation of significant infections prevention through strategies to reduce risks and prevent infections control of infection prevention activities reporting surveillance data  Goal of infection control: Reduce risk of hospital acquired infection( nosocomial infection). Processes involved in Infection Control program “Surveillance /control cycle” Surveillance types: 1. Total Surveillance EX.(infection rate) 2. Targeted Surveillance Ex.(CAUTI,CLABSI) This is often called 'focused' surveillance. This type of surveillance is conducted to measure the occurrence of specific infection problems, or to confirm an outbreak The Centres for Disease Control and Prevention (CDC)  is the national public health institute of the United States.  Its main goal is to protect public health and safety through the control and prevention of disease, injury, and disability.  The CDC focuses national attention on developing and applying disease control and prevention  The national Healthcare Safety Network: 1. IT is a tracking system utilized by the CDC to identify infection prevention problems To utilize the information obtained for benchmarking. 2. To comply with mandatory public reporting state and federal mandates, and to encourage national efforts towards the elimination of healthcare acquired infections. 3. Organizations participating in this database network include acute care hospitals, psychiatric and rehabilitation hospitals, outpatient dialysis facilities, long-term care facilities and ambulatory surgery centres. 4. The NHSN website, provides definitions, guidelines for data  The national Healthcare Safety Network component:  Patient Safety Component: 1. Device associated Healthcare Acquired infection 2. Surgical site infection 3. Multi drug resistance  Long term Component: 1. MDRO 2. CAUTI  Healthcare Personnel Safety: 1. Healthcare personnel exposure module 2. Healthcare personnel vaccination module Environment Safety Program:  Environment of Care Committee (EOC), sometimes called the Safety Committee, is a multidiscipline committee that is responsible for the care of the environment and the individuals that function within that environment.  This committee includes representation from throughout the organization but specifically includes members of the Facilities staff, senior leadership, quality improvement staff, the Infection Preventionist and the Risk Manager.  This committee is charged with monitoring seven areas of the organization: 1. Safety 5. Hazardous Materials 2. Security 6. Medical Equipment 3. Fire Safety 7. Utility Management 4. Emergency Management  One of the functions of this committee is to conduct a periodic survey (often called rounding) throughout the facility on a routine basis looking to identify hazard, potential areas where risks, infections and other things can occur.  The risks identified must be handled as soon as possible and then tracked and discussed at the EOC meetings to identify patterns, trends, and needed improvement activities.  Financial Management 1. Financial management is the study and control of money resources to meet the goals and objectives of the organization. 2. Linking the annual budget process to daily operations. 3. It is one of the most objective forms of performance measurement, particularly for the dimension of efficiency. Analysis Financial Financial and plan Monitorin variance (budget) g reporting Financial plan How the organization will (budget) allocate and use its resources? Basis of financial performa Quantitati nce evaluatio Cost ve control expressio n n Sense of financial responsib ility Financial Organisation monitor the annual budget to meet the Monitorin financial target and strategic goals. By: g 1. Balance score card 2. Recognition Analysis and variance A management review tool to compare predicted reporting revenues and expenditures versus actual one.  Decisions regarding future staffing, services, supplies, and capital are made based on budget analysis.  Financial statements :show budgeted vs. actual amounts spent for the month, quarter, and/or year-to.date(monitored all the time)  Variance reports :Internal warning systems alerting managers and higher level management to possible excess expenditures, inaccurate accounting.  Cost analysis Comparing/evaluating method: quantitatively all costs incurred and benefits returned for each  Return proposed Onservice or program. Financial ratio used to calculate the benefit an investor will Investment: receive in relation to their investment cost. The Role of the Quality/Utilization/Risk Professional in Organizational Preparation for Quality Management/Performance Improvement : Secure the approval, support, and commitment of all key players, which at a minimum includes the governing body, administration leaders, medical staff leaders, medical directors, nursing leaders and other clinical and support service directors/managers. Leaders each must make a personal commitment and be willing to participate in Q/R/U management strategy development and implementation. All others in the organization must see leadership develop a passion for Q/R/U management. The healthcare quality professional must have the leadership skills  Thank s Mohamed Eldeeb CPHQ,CPHRM,LSSBB,TQM,SCRUM Master ,TOT , Team STEPPS master training