Humans and Systems Error Response

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Respond to discussion 1, 2, 3 DISCUSSION 1 : The Institute of Medicine released a report called To Err is human: Building a Safer Health System. When humans are involved, errors will occur. There are three strategies to help prevent or decrease errors including preventing, recognizing, and mitigating harm from error. Recognizing and implementing actions that prevent error have the greatest effect. We must first realize our error before we can understand how to prevent it from happening again. There is both system and human error. An employee can be reprimanded for making a mistake but that will not prevent it from happening again. An event needs to be looked into to determine the cause of the event. Was there a system issues that caused this event? Management and leadership have a major role in improving safety and help create a culture that encourages recognition of an error and learning from those errors. IOM has nine categories that they feel could help improve safety. The all focus on goals to avoid putting healthcare working in a situation where errors could happen. The goal is to create financial and regulatory incentives to help create a safer healthcare system and systematic way of integrating safety into the process of care (Donaldson, 2008). In Crossing the Quality Chasm: A New Health System for the 21st century, the discuss the need for improvement in safety and quality. It indicates that changes must be made on all levels, including clinician and patient relationships, operation department of the health care organization; financial department; and the regulatory and liability environment. Quality problems generally do not come from a lack of knowledge, training, or effort by health professionals. There is a lot of information regarding EBP, too much to even try to retain, but there is a list of performance characteristics that could help lead to safer and better quality of care for patients. Their care should be safe, effective, patient-centered, timely, efficient, and equitable (IOM, 2001). Getting to a higher safety level is the first step in improving overall quality of care. Care should be evidence based, it should be focused on individual needs, and completed in a timely manner. Fee-for-service payment models are huge drivers in high healthcare spending. The model pays providers for each service that is performed, which has shown to lead to unnecessary care being provided. This model was started when providers were mainly seeing patients for acute illnesses versus now when they see them for chronic problems also, which often includes multiple visits. The risk/reward system is an example of the value-based payment model. This model reimburses providers at a fixed rate, the main goal is to improve the patient experience, the health population, and reduce costs. One type of VBP is the bundled payment model. This model reimburses the provider with a lump sum for each episode of care they provide. It is a risker model than the fee-forservice model, since providers have to order all services that the patient would need during a visit, CMS has started a mandatory bundle payment model called Comprehensive Care for Joint Replacement (CJR) program. These programs make the hospitals accountable for their quality and cost of care for Medicare patients who undergo knee or hip surgeries. The risk/reward system is better to incentivize quality improvement as the main goal to improve patient experience, which includes satisfaction and quality, where the fee-for-service model is aimed at reimbursing providers for services whether they are needed or not (Knickman & Elbel, 2019). The Physician Compare and Minnesota Community Measures websites are both aimed at driving quality improvement through public reporting. They help people find quality health care reports so they can see accurate ratings of different providers. CMS has its own website also called Physician Compare for patients on Medicare. Patients can find PCP based on individual needs and their distance from their homes. They can also compare physician/groups and performance information that is listed on the website. They can find physicians according to body parts they are concerned about and what medical topic they may have. They can find specialty clinics in their area, performance information is also available with patient survey scores, which can help find a quality HCP based on patient feedback. The PDSA process is a cyclical process that has a constant potential for improvement. The cycle of improvement could theoretically continue forever as improvement teams could always target new issues and seek greater improvements. The Lean process gets rid of waste and streamlines the process. The Six Stigma process uses the definemeasure-analyze-improve-control (DMAIC) methodology, which is driven by data to solve problems (Atlin, 2019). I would use the PDSA process for my improvement plan. I would first write my aim statement, which should be SMART. The quality incentive is to have >90% of SNF residents have an advance care directive in their chart and EHR, by 12/31/20. Advanced health directives are discussed at Dr appts, hospital visits, and on SNF admission, but many of them do not have them arranged or on file. Education is given on admission by social services in their admission packets and also again by nursing staff to answer further questions that the social worker may not have answered. Advanced directives and DNR forms are not talked about as much as they should be at these different interactions until most of the time at end of life. Currently at the facility that I work at, approximately 50% of our residents have an ACD at least on file, approximately 25% of admissions have ACD in place but do not know where the papers are for it. Data will be pulled each month to ensure that we are reaching our goal and that the plan is working. If an improvement is noticed we will continue with the process, if it is not improving, we will work on a new process plan. References: Atlin, C. (2019, January 4). HiQuiPs: Implementation part 2 – Which strategy to choose: PDSA, Lean, or Six Sigma?. In Canadiem. Retrieved from https://canadiem.org/whichstrategy-to-choose-pdsa-lean-or-six-sigma/ Donaldson, M. S. (2008, April). An overview of to err is human: Re-emphasizing the message of patient safety. In NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2673/ Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001. 2, Improving the 21st-century Health Care System. Available from: https://www.ncbi.nlm.nih.gov/books/NBK222265/ Knickman, J. R. & Elbel, B. (Eds.) (2019). Jonas and Kovner's health care delivery in the United States. 12th Edition. Springer Publishing. DISCUSSION 2: Richardson et al. (1999) provided a review of a report provided by the Institute of Medicine of the National Academies, and how they have established a pathway for improved quality in health care. Part of their review included establishing national safety goals, tracking safety progress, and encouraged investment in medical error prevention. Richardson et al. (1999) reported on the need for increasing the use of reporting systems and how data should be used for research on improving processes to safeguard quality care. Richardson et al. (1999) promoted re-examinations of all modalities within health care as a means to promote competency, increase safety, and in turn would promote financial incentives for health care organizations. Rau (2015) reported on hospital performance and the financial incentive programs used to help increase quality. Rau (2015) reported that 800 hospitals out of 1700 earned a bonus for quality performance. A majority of hospitals were then left with penalties through value-based purchasing programs due to hospital acquired infections or readmittance within a 30-day time period. Rau (2015) that more than six percent of Medicare payments are contingent on performance and this drives hospital systems to change practice to improve quality outcomes for patients. The positive aspect of valuebased purchasing is that hospital systems are still afforded an opportunity to achieve bonuses even though they still have room for improvement. Conrad and Perry (2009) reported that physicians whom own financial ownership in their practice respond positively to quality-based initiatives because they will benefit from any value added to their practice. Conrad and Perry (2009) also reported that providers that are part of a group are able to benefit from the quality of their partner even if their own quality performance is subpar. Conrad and Perry (2009) pointed out the extrinsic and intrinsic factors involved in quality performance when it comes to behavioral science. The extrinsic factor is the financial reward or penalty versus the intrinsic factor of self-improvement and duty to improve quality care. Conrad and Perry (2009) reported that larger reward systems can overly influence intrinsic factors that naturally incentivize the provider to participate in quality improvement. Overall, Conrad and Perry (2009) argue that relatively long term, organizational and individual incentives will provide quality improvement. Roland and Dudley (2015) reported that fee for service can stimulate quality when competition is spurred by improved performance. Roland and Dudley (2015) also argue that fee for service does not provide quality incentives for team based care, does not consider overall health care costs, and it may increase patient bias. Physician Compare is provided by CMS. This is intended to locate providers that serve Medicare and Medicaid. This will provide a list of providers based on location from where the patient lives. This can compare up to 3 providers or provider groups. Performance information is available about recommended care. These services are aimed at providing public information on quality performance of providers or groups of providers. The aim is to provide a means of increasing competition for services. The quality improvement method that I would use is PDSA. I would like to use this method to look at improving pre-operative communication to patients. Our department has had difficulties with poor understanding of the requirements for patients on the day of their procedure in regard to sedation. This is particularly difficult when more than one service is involved with planning and implementing the care for the veteran. In the last three days we have had five extensive cases that have involved anesthesia. Two out of the five cases were either delayed or cancelled due to the patient eating or taking medication that they should not have had prior to their procedure. I would plan to have someone from our department make contact with the patient on the day prior (either by phone or other preferred technology) to their planned procedure to ensure that preoperative teaching was reviewed and the patient was able to teach back information in regard to patient requirements. The main objectives would include NPO status, medications to stop or continue (this would be addressed on initial scheduling and on day prior), and ensure that the patient had a driver or inpatient observation status would be established. I would research how many cases were delayed or cancelled due to failed communication in the last quarter. The goal would include an 80 percent increase in the following quarter after implementation of increased contact with the patient. References Conrad, D. A., & Perry, L. (2009). Quality-Based Financial Incentives in Health Care: Can We Improve Quality by Paying for It? Annual Review of Public Health, 357. Retrieved from https://www-annualreviewsorg.xxproxy.smumn.edu/doi/pdf/10.1146/annurev.publhealth.031308.100243 Rau, J. (2015). 1,700 Hospitals win quality bonuses from Medicare, but most will never collect. Kaiser Health News. Retrieved from https://khn.org/news/1700-hospitals-winquality-bonuses-from-medicare-but-most-will-never-collect/ Richardson, W.C., Berwick, D.M., Bisgard, C.J., Bristow, L.R., Buck, C.R., Cassel, C.K., Chassin, M.R., Joel Coye, M., Detmer, D.E., Grossman, J.H., Brent, J., Mck. Lawrence, D., Leape, L., Levin, A., Robinson-Beale, R., Scherger, J.E., Southam, A., Wakefield, M., & Warden, G.L. (1999). Preventing death and injury from medical errors requires dramatic system-wide changes. The National Acedemies of Sciences Engineering Medicine. Retrieved from https://www.nationalacademies.org/news/1999/11/preventingdeath-and-injury-from-medical-errors-requires-dramatic-system-wide-changes Roland, M., & Dudley, R.A. (2015). How financial and reputation incentives can be used to improve medical care. Health Research and Educational Trust. DOI: 10.1111/14756773.12419 DISCUSSION 3: The Institute of Medicine (IOM) discussed ways to improve quality in healthcare. In To Err is Human, the IOM identified three ways that could help improve patient safety. They stated that the government should create a national center for safety, healthcare organizations should have mandatory and voluntary safety and quality reporting, and that healthcare organizations should work to foster a work environment that encourages change and growth with a focus on safety (IOM, 1999). In Crossing the Quality Chasm, the IOM outlined a very extensive plan to help improve healthcare delivery. What stood out to me the most was the focus on care coordination and helping patients ensure that they have access and help navigating the healthcare system. The IOM also advises that healthcare providers and insurers adopt a patient-centered approach, which could help reduce costs and help improve quality and safety since many more patients are becoming chronically ill with multiple complex conditions (IOM, 2001). A similarity between To Err is Human and Crossing the Quality Chasm is that both stressed the importance of healthcare organizations and leaders to create a work environment that encourages education and positive changes, and not focusing on retribution or punishment for safety errors or medical mistakes (IOM, 2001). I think it is meaningful that they included this as a quality improvement strategy because it can be very hard to change the culture within a hospital or other health care setting. As Knickman & Elbel (2019) stated, fee for service programs were more applicable when a majority of care was focused on acute problems, and now that treating more chronic and longterm conditions taken more of a front-seat in healthcare, fee for service is not really working as far as reducing health care costs. I would argue the fee for service does not do much to incentivize quality improvement, as it has been shown that this type of payment has led to unnecessary care and costs being provided, which does not increase the quality or value of a patient's care (Knickman & Elbel, 2019). Risk/reward incentives are more along the lines of pay for performance models or penalty systems. There does not seem to be an overwhelming amount of evidence that shows that this type of financial incentive improves quality either. Also, according to a Kaiser Health News report, many hospitals that qualified for bonuses based on quality initiatives like a reduction in hospital readmissions may also receive penalties based on quality numbers like increased hospital acquired infections (Rau, 2015). So, some hospitals may break even, lose money, or gain based on their quality numbers. While I do think this is probably the better way to incentivize quality improvement, it could also lead to hospitals and organizations to work more on what they know may earn them bonus payments, which could pull focus from areas that need improvement. Knickman & Elbel (2019), wrote that public reporting can help improve quality in three ways: allowing consumers to research and “shop” around, insurance providers can create care networks with high-performing organizations, and public reporting allows for providers to review how they are doing compared to their peers. Minnesota Community Measures is a website that provides valuable quality information. It provides information regarding health care costs in inpatient vs outpatient settings, clinical quality measures that allow patients to see how their health care organization compares to others in the state, and it also has reports regarding disparities in care based on race, language, ethnicity and country of origin (MCM, 2020). Personally, I think this is great information to have, but looking at some of the reports there seems to be some health care organizations that do not have any quality information listed. I think it would be wise to possibly require public reporting because it not only shows transparency, it may also create an incentive for providers to incorporate more quality improvement strategies when they are able to see how they compare to their competitors/peers (Knickman & Elbel, 2019). Also, I am surprised that as a healthcare consumer myself, I have never researched my health care organization. We have so much information at our fingertips that helps us make informed decisions about what products to buy, it only makes sense that we should be doing the same research to ensure that we are receiving high quality health care. The PDSA (plan-do-study-act) cycle is used to create change by asking three important questions: what needs to be done, identifying if the change was an improvement, and identify if there are any changes that can be done in the cycle to create an improvement (MDH, n.d.). As a care coordinator RN, I am both directly and indirectly responsible for quality improvements. For example, I work with many patients who have diabetes, and even though I do not work through a registry that identifies patients and what they specifically may need help with (like blood pressure control), I do work with selected or referred patients to better control their diabetes and educate them on ways they can help meet their goals. I think the most difficult part of care coordination is patient involvement and motivation. I do not believe that I should work harder than the patient on their own health care, but should be available as a resource to help them achieve their goals. One way to potentially improve engagement is to meet with the patient initially in person while they are seeing the provider, and then making sure to check in face to face with them at subsequent follow ups. This could show and remind them that I am available to help them, and it may encourage the patient to answer when I call and also reach out to me when needed. After a few months, I can determine if the patient has been following up and meeting their goals, or if they have not. For those that are following up, I do not think any changes for improvement would need to be made. For those that are not, it may be beneficial to go more in depth as far as assessments, like determining their health care engagement, changing their care plan, or discussing if they have any other preferred means of communication. It is important to reflect and look at what is working and what is not working during the PDSA cycle because changes can be made relatively quickly that can lead to different and improved outcomes in the cycle. References Institute of Medicine (IOM). (1999). To Err is Human: Building a Safer Health System. Retrieved from https://www.nationalacademies.org/news/1999/11/preventing-death-and-injuryfrom-medical-errors-requires-dramatic-system-wide-changes Institute of Medicine (IOM). (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Retrieved from https://www.nap.edu/read/10027/chapter/2#20 Knickman, J. R., Elbel, B. (Ed’s). (2019). Jonas & Kovner’s Health care delivery in the United States (12th ed.). New York, NY: Springer Publishing. Minnesota Community Measures (MCM). (2020). Community Reports. Retrieved from https://mncm.org/reports/#community-reports Minnesota Department of Health (MDH). (n.d.). PDSA: Plan-Do-Study-Act. Retrieved from https://www.health.state.mn.us/communities/practice/resources/phqitoolbox/pdsa.html#:~:t ext=PDSA%2C%20or%20Plan%2DDo%2D,works%20and%20what%20doesn't. Rau, J. (2015). 1,700 Hospitals Win Quality Bonuses From Medicare, But Most Will Never Collect. Retrieved from http://kaiserhealthnews.org/news/1700-hospitals-win-quality- bonusesfrom-medicare-but-most-will-never-collect/
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Discussion 1 Response
Errors are indeed at times inevitable, and it is essential to understand if it is either
human error or system error. Just as in the discussion, to avoid human error, rigorous
training should be conducted to the various professionals. On the other hand, to help
reduce system error, the multiple facilities should ensure that the system put in place
is highly reliable, thereby reducing cases of s...


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