Quality Risk Management Plan
Jonesky is a Russian patient who presented to the emergency room with her husband after being sick for two days with vomiting, she spent several hours waiting in the emergency room before her husband approached the emergency room desk to try to explain that his wife is getting worse and she is in severe pain. Jonesky had a appendicitis and she was presented at the operation room in order to do a surgery, while the nurse wrote the name of Jonesky as Jone because of her Russian accent, while there was another patient of the name of Samantha Jones presented to the operating room to fix her broken ankle because of a fall. The two surgeons were too busy that day and they didn’t do the time-out procedure as they were suppose to do it, which caused that both of them were starting to do the operation on the wrong patient, as one surgeon started to do the ankle incision on Jonesky, while the other one was doing the appendicitis incision for Samantha which had the ankle fracture.
As a Chief Risk Management Officer for the hospital, I will be discussing some of the risk analysis, risk management and quality improvements plan that could be applied in the hospital, in order to avoid these types of errors, improve the quality of care and patient satisfaction.
The first step towards the improvement is to develop a risk management plan, which consists of Identification of core strength and values, assessing the environment, key success factors, goals and strategic initiatives and tactics ( Youngberg, 2011 )
Identification of core strength and values by understanding the strength and weakness of the hospital, which can be assessed through the SWAT analysis chart of identifying the strength of the hospital which could be good communication and mediation skills, strong technical skills, high quality professionals, high innovation and creativity, big budget, excellent hospital facilities, understanding of the legal system and ability to manage multiple crises. The weakness could be having the CEO with some personal interest in disadvantage and ethnic minority population group, shortage of critical staff, lack of adequate resources, opportunities could be growing metropolitan community, increase managed care work, growing healthcare community program, while the threats could be reducing the government reimbursement and increase the competition from the healthcare provider network ( Gretzky, 2010 ) Identification of core strength and values also include the risk assessment ( by identifying a specific situation that could put patient in risks, identifying the root cause analysis, and estimate the economic values), risk finance and risk control ( by design an innovative approach to decrease the risk, educate the personal and understand the legal )
Assessing the environment, which could be internal environment by being decentralized with the management more than being centralized, proactive, focus on free market and the external environment assessment by process managing care across the continuum instead of episodes of care, promoting health, data widely shared, ethical standards steps by consumers and various legislators ( Youngberg, 2011 )
Key Success Factors for risk management, which includes a development of proactive process to identify the severity of the risk, the hospital’s risk tolerance, develop a strategy to control the systemic clinical and administration as well as an innovative strategy which serves towards increasing the patient quality of care and collect any risk information which could help later in identifying the risk management plan ( Youngberg, 2011 )
Goals and objectives are one of the essential components to develop a risk management plan towards the quality improvement, as one of the goals could be developing a process that support rational, ethical and safe practices and the objectives of this goal could be increase the number of ethical consult, increase the number of protocols that uses the technology before buying any new equipments, annually decrease the number of unethically lawsuit cases ( Youngberg, 2011 )
Eventually set the strategies and tactics that would implement the goals of the risk management plan, such as implementing a set of services that would actually help the hospital to manage the risk of patient across the continuum ( Youngberg, 2011 )
The second step towards improving the quality of care and risk management is to focus on the contextual factors such as; quality of relationships, communication, team work, leadership styles, organizational cultures, team process and behaviors..etc. Based on the survey completed by 420 attendees for one and half hour work-shop for transformational leadership which was given at quality improvement conference at 2014, 88 % of the attendees admitted that the main quality improvement problems are coming from relationship reasons more than the technical causes, and the relationship issues were identified as the ways of communication and leaderships, motivation and behaviors, the ways meetings held and processed, while half of the attendees reported that these relationship issues required four times attention than the technical issues, 92 % stated that they have a current relationship issue that interfere with their work life and 58 % of these relationship issues had been going for six months or more ( Baker, Suchman & Rawlins, 2016 )
The relationship issues have a great impact towards improving the quality of care by integrate multiple perspectives towards understanding the work process and by understanding that the team work is the key for success and that individual work wont improve any quality of care and at the same time that could arise some conflicts because of the interaction of the individuals within the group, the second relationship issue is the resistance to change, especially when any change happen within a hospital, some loss will be expected, the third relationship issue is the gaining of commitment and not just the compliance, because the commitment is the key to go through complex tasks and the feeling that all the individuals are involved and participating in the change ( Baker, Suchman & Rawlins, 2016 )
The core competencies that every health clinician should posses are providing patient centered care and that should be applied first on the CEO and then going down to all employees as to respect the patient’s values, believe, preferences, differences, and to work on meet the needs of the patient, relieve their pain and suffering, and to interact them in the decisions as well as listen, inform, educate the patient about their condition with dignity and respect, because that will improve the quality of care, increase the patient rapport and decrease the lawsuits. Work in interdisciplinary team as we stated before about the contextual factors in improving the quality of care and work in a team environment. Employ evidence based practice and that’s through improving the research and development department within the hospitals to improve the research process. Apply quality improvements and utilize informatics to communicate, manage knowledge, decrease errors and use information technology to support decisions ( National Academy of Science, 2003 )
The third recommendation is profiling as part of Continuous Quality Improvement, as CQI has a management system that allows the process to be analyzed and the outcomes to be evaluated and improved by the integration of structure ( hospital, equipments, human resources..etc ), process and outcomes ( effect of the care on improving the patient condition and health )and as part of the CQI strategies, I will use the Benchmark strategy to improve the quality of care and maintain the most competent physician staff ( Joshi, Ransom, Nash, Ransom, 2011 )
Benchmarking is” the process of collecting and analyzing data to identify trends in performance and when compared with other collectors of the same data, identifying best performers and determining if interventions that were introduced to address identified problems decreased the desired results ” ( Youngberg, 2011 )
There are different types of benchmarking; Internal benchmarking, as the hospital could benchmark among similar structure, process, operation and outcomes, or could be benchmark with another hospital or organization that has the same process and could be compared together, Competitive benchmarking, as the hospital compare the structure, process, function and outcomes with the most closed competitors in the market and to get the advantage of identifying the major improvements, position of the hospital’s services in the marketplace, identify the competitors’ advantages, Functional benchmarking, which is thinking outside the box, by comparing the major problems of the hospitals such as the fire safety and compare it with the large organizations such as the hotel which apply this fire safety very well, and the last type of benchmarking is the Generic benchmarking and is best used when there is an issue which needs significant improvements ( Amerinet )
There are few prerequisites for the benchmarking: the commitment of leaderships, have a good experience with the Continuous Quality Improvement, preparation of the organization and identification of the key process ( Amerinet ) and at the same time the physicians shouldn’t held accountable for Continuous Quality of Care only by themselves, because simply before applying any physicians variability, I will make sure to include some easy steps such as take a close look on the organzioational process, as the length of stay of the patients shouldn’t be the physicians responsibility if the case managers are not working on discharging the patients, review the physicians variability during a high volume of strategically meaningful procedures, comparing the physician’s performance through using of any of the benchmarking types ( Udwiin, 2015 )
There are different tools to be used in order to apply the quality of care:
Check sheet: it is a tool for qualitative and quantitative data gathering and collection, and it is useful for all phases of Lean Six Sigma DMAIC framework ( Kollengode, 2010 ) the check sheet is a custom designed tool, to collect information on a frequency of occurrence, and it could be used for example to document reason for interruption in the operating room like the Jonesky case that we have, it can be used in the situation where the data can be collected with the same person or the same location, and it has many advantage as it is a simple way to collect data, it’s first step to identify the nature of the problem ( Kollengode, 2010 )
Histogram, Cause and Effect, Pareto Chart and control chart are all different ways of tools of the quality improvement.
The Two recommendations that could avoid the existence of this incident would be:
1) Application of an accurate and correct Time-Out procedure before the operation, as the time-out is a short meeting between the whole staff of the operation immediately before the initiation of the operation in order to verify the patient identification, the procedure, the site and any other patient’s information. The problems with the time-out procedures are sometimes the whole crew don’t stop and participate in the procedures or as happened in Jonesky case, that the staff are overloaded and tired so they expedite the time-out procedures. In order to avoid the errors in the time-out procedures, Identify the risk by using the Joint Commission Targeted Solution Tool in order to identify the risk and develop different strategies to avoid any risks to happen, standardized the booking process, as there should be a standard way of scheduling and not a mixture of using emails, phones and faxes as well as not using any
disapproved abbreviations that could make an error with the surgery site, assigning specific roles in order to be working in a team work and not mixing and confusing the roles, reference the site mark by confirming the site of the surgery with the entire crew and to mark as well, and not to rush, as the problem with Jonesky at the hospital was the rushing through the time0-out procedure because of the busy day, as sometimes organizations are mentioning that the biggest challenge for the time-out procedures is not to rush it and complete the time assigned before starting the operation ( Rodak, 2013 )
Marking the surgery site is one of the challenges that the surgeon goes through at the time-out procedure, as it is preferable to involve the patient with the mark site if it’s possible, mark the site before the operation, the mark is made near to the operation site, the mark is sufficiently permanent to be visible, adhesive markers are not the sole means of marking the sites ( The Joint Commission )
2) The second recommendation is the accuracy in taking the patient information through the emergency room, as if the patient was not speaking English and she speaks only Russian and her husband doesn’t speak a well English, the nurse should be very accurate with taking the patient information and the nurse should review the patient identity with the patient and her husband and if the nurse couldn’t get an accurate information, they should facilitate the presence of a translator or at least get the information of the patient through the patient ID.
3) The third recommendation is the surgical site marking, as marking the correct surgical site is very essential towards having the correct procedure done, and there are some accurate procedures that is preferable to go through such as not marking the X mark because that could be misunderstood that this is not the right site, the use of non permanent markers that could be going away during the procedure, making sure that there is noa any additional mark from a previous procedures that could confuse the staff, imprecise site marking; which is marking for example the knee joint, without identifying what kind of procedure will be held in the knee joint, it could be meniscus removal or repair, or knee replacement or even a repair of any of the knee ligaments, and also sometime the site marking could be contraindicated or couldn’t be applicable in some situations, such as the teeth, infants or some mucosal sites that the marking wouldn’t be applicable ( Stahel, Mehler, Clarke & Varnel 2009 )
The risk Care managent is a part of the quality improvement, and the existence of the risk manager office is a very essential step towards achieving the quality of care within the Metropolitan hospital which will impact the quality of care within the community of the hospital and getting the patient survey after any treatment or procedure will allow of more improvement of quality of care.
Stahel, Mehler, Clarke & Varnel ( 2009 ), The 5th Anniversary of The Universal Protocol, retrieved from https://pssjournal.biomedcentral.com/articles/10.1186/1754-9493-3-14
Baker, Suchman, Rawlins, 2016, Barriers of Quality improvement, retrieved from
Rodak, 2013, 5 Takeaways for Surgical Time-out Success, retrieved from http://www.beckershospitalreview.com/quality/5-takeaways-for-surgical-time-out-success.htmlThe Joint Commission, The Universal Protocol, retrieved from http://www.jointcommission.org/assets/1/18/UP_Poster.pdf
National Academy of Science, 2003, The Core Competencies needed Healthcare Professionals retrieved from https://www.ncbi.nlm.nih.gov/books/NBK221519/
Wayne Gretzky, ( 2010 ) Strategic Planning and SWOT Analysis, retrieved from https://www.ache.org/pdf/secure/gifts/Harrison_Chapter5.pdf
Amerinet, The Benefits of Healthcare Benchmarking, retrieved from http://www.intalere.com/Amerinet%20Documents/Amerinet-Benchmarking-Whitepaper.pdf
Youngberg, B.J. ( 2011 ) Principle of risk Management and Patient Safety. Sudbury, MA:Jones and Bartlett
Joshi, M.S, Ransom, E.R, Ransom, S.B, & Nash, D.B. (2014). The Healthcare Quality Book ( Third ed. ). Arlington, VA: Health Administration press.