Risk Management Overview - PowerPoint Presentation

Slide1

Risk Management Overview and Associate Responsibilities for SafeCare

General OrientationSlide2

Objectives for Risk General OrientationTeach you how to respond and report safety concerns and eventsEvent Reporting WhatWhy

HowWhenReview associates responsibility and

accountability

for patient, personal, peer and environmental safety

Introduce you to

SafeCare

expectations and Red Rules for all associatesSlide3

STH Risk and Patient SafetyConnie Esper-Kanze- Ex. Director Risk Management STH ST Rutherford- Lonna Spain, Risk ManagerST West- Lisa Dillehay, Risk Manager ST Midtown- Sherry Wix, Risk Manager

ST Hickman-Dee Hoover, Risk, Case Management, Quality and CNOST River Park, ST Highlands, ST DeKalb, ST Medical Partners (STMP), ST Stones River- Connie Esper-Kanze, Ex. Director Risk Management STHSTH Risk Coordinator-Rebecca Rock

STH Risk Coordinator- Phyllis McElroy

Claims Coordinator- Linda Poteete

Grievance – Krista Bierly

Administrative Assistant-Chris McClaskeySlide4

Risk Management areas of ResponsibilityEvent Reporting- maintain system event reporting system; review each event posted by associate. and review of each event posted by associatesLoss Prevention- Preventing an event from occurring by designing systems/processes safely or preventing events from happening again (Lessons Learned)Patient Safety- focus on preventable harm to patients through the SafeCare and High Reliability Organization initiativesRisk Finance- Insurance including: general liability, property, aviation, auto, professional, etc.Claim

- formal demand (written or oral), short of a lawsuit, which seeks damages and may include a Notice of Intent, an attorney’s demand letter, an attorney representation letter or a letter from the patient or family seeking compensation or complaining of an injury allegedly caused by improper treatment or lack of treatment.Lawsuit- formal mediation proceedingGrievance- providing follow up to formal allegations of dissatisfaction that

are

made to the hospital by a patient, or the patient's

representative, and were not resolved during the patient’s hospital staySlide5

Event ReportingEvent is defined as any happening/occurrence which is not consistent with the normal or the routine operations of

the organizationAll associates

are

responsible and accountable

for reporting events that

are not

consistent with normal

routine in the Event Reporting System (ERS)

Events to report include:

Actual

events- events that reach the patient that

may or may not

cause harm

Near Misses- “great catches” staff make to prevent an event from reaching the patient

Visitors events

Facility/Plant events or unsafe conditionsSlide6

Event ReportingMEDICAL RECORD DOCUMENTATIONDocument in “EVENT CHARTING” or in narrative notes in Cerner

Document the factual, objective, non-emotional information of what happened and what you did to address the event

Do not

tell the patient or family you are entering a report

Do not

document that you are entering

an event report

Do

not

point

fingers or blame others

WHY Report

:

Alert

us that something has happened or could happen

Gather facts/evidence

while it is fresh on everyone’s mind Root Cause Analysis (RCA) may be needed to make improvements

WHEN to report

Immediately (online or phone call

) before leaving shift

WHAT to

report

Objective

and factual information, persons or departments involved

CONFIDENTIAL

Do not make copies

of medical record notes or

reportsSlide7

Reporting ExamplesThreatening or Abusive behavior by anyone  Patient RightsTo receive safe, high quality, compassionate and  respectful care, without fear of intimidation of any kind, including abuse- physical, emotional, verbal, intimidation, etc.)  There is

mandatory reporting of any suspected abuse of a patient by anyone.Zero tolerance of physical, verbal, or emotional abuse including intimidation by anyone. Report any abuse or suspected abuse immediately.

Examples: (co-worker to co-worker, supervisor to associate, physician to associate, patient to associate or associate to patient)

Associates or patients should never be subjected to abuse or intimidation.Slide8

Reporting ExamplesPhysical harm to patients, visitors or associates by any partyPatients leaving AMA or elopementMedication events (omissions, wrong meds, wrong dose wrong time, wrong patients, wrong route, etc.)- ACTUAL or NEAR MISSES

Unexpected outcome of a procedure or treatment (even if considered a risk of the procedure)

Injury

(i.e.,

Burns, nerve injury/damage not present on

admission

Retained

foreign body left in patient or found in

patient

Falls

or slips (with or without injury

) Unexpected death

Unplanned returns to surgery

Slide9

Equipment malfunctions or defects that have caused injury or have the potential to cause harm (SMDA reporting) Loss or damage of property, valuables, belongings (hospital, patient, staff, visitor) Lack of informed consent Adverse reactions to medication Transfusion reaction

Wrong surgery, procedure or treatment (wrong side, site, patient) Injury to or removal of healthy organ or body part Confidentiality breaches

Over-sedation (use of reversal agents)

Post-Op

Death, CVA (stroke), MI (heart attack), excessive bleeding, etc.

Reporting ExamplesSlide10

MANDATORY REPORTING IS REQUIRED FOR ALL “BASKET 1” SERIOUS EVENTS TO ASCENSION BY RISK MANAGMENT WITHIN 10 DAYS OF THE EVENT“Basket 1” Events are those that result in severe permanent injury or death. Investigation of these events should be given priority over other open investigations to meet this requirement. Slide11

Event Reporting (current)For Hospital staff: Go to the LifeNet page and click on your ministrySlide12

Log in using tnnas\username and password when keying in an event for your primary (home) facility. If working at an alternative site, log in as a guest , select facility and key in your name and contact information at the end of the event.Slide13

Select a safety event involving a patient, visitor or facility/plant event or

feedback ticket for a compliment, suggestion or complaint under the correct facility or hospital to complete event information. Slide14

Click on DOERS for Event Reporting ofAssociate Injuries including any workplace violence injuries to associatesSlide15

Alert Risk Management of any demands for compensation (claim), threats of lawsuitsNever keep notes or copies of notes/medical records regarding an adverse event in your own personal files. Give notes/copies to risk management for protection from discovery/safe keeping

Never speak with or respond to an attorney about a hospital issue without consulting the Risk Management Department, First!

Depositions/Trials

– Risk Management will guide you through the processSlide16

Patient Safety - It is the expectation of each patient that as they are trusting us with their healthcare, we care for them without preventable harm.

Associate Safety - As your employer, it is important to Saint Thomas Heath that you go through your shift safely and without injury.

Environmental Safety

-

It is our goal for all who enter our facility/grounds to be safe.

SafeCare

error prevention techniques apply to allSlide17

I am accountable for and commit to:

Patient, Personal, Peer and Environmental Safety

“I will demonstrate (200%) commitment to patient, personal, peer (co-worker) and environmental safety .” We watch out for one another.

2.

Clear, Concise and Complete Communications

Be responsible for professional, accurate, clear and timely verbal, written, and electronic communication.

3.

Having a Questioning Attitude

“I will ‘think it through’ and ensure that my actions are the best.”

4.

Paying Attention to Detail

“I focus on the task at hand to avoid unintended errors.”

STAFF EXPECTATIONS

17Slide18

Patient, Personal, Peer and Environmental SafetyWhat does 200% accountability mean? It is simply peer to peer accountability. We help each other when we see unsafe behaviors with the use of: ARCC Ask a question Request a change Voice a Concern Chain of command

Error Prevention TechniqueSlide19

In the face of uncertainty… When in doubt…….When unsure……..Review your planResolve the concern

Reassess your actions

Ask for help

Get the right people involved and be diligent in the use of error prevention techniques.

Stop & Resolve

19

Error Prevention TechniqueSlide20

Clear, Concise and Complete CommunicationsUse 5P handoff when transferring responsibility of a patient or project to a co-worker: Patient or Project Plan Purpose Problems P

recautionsUse SBAR to communicate concerns or make requests:Situation Background Assessment Recommendation

To assure you have complete information or be sure you understand information use:

Repeat- Backs/Read- Backs with 1 or 2 Clarifying Questions

Use Phonetic clarification; A=Alpha and Numeric clarification; 50mg as in five-zero

Document legibly and accurately. Slide21

Paying Attention to DetailUse STAR to focus on tasks: Stop. The risk of error drops dramatically when you pause – even for a couple of seconds – before performing a critical act.

T

hink

.

When you stop, think about what is important about what you are about to do.

A

ct

.

Perform the act.

R

eview

. Did you get the results you expected? Slide22

RED RULESAlways use “two patient identifiers” with each and every patient encounter (name and birthdate routinely)

Always use departmental identified

Double Checks

(Check with your department during orientation)

An act that has the

highest level of risk or consequence

to a patient, a peer, an associate or environment safety if not performed exactly

,

each and every time

.Slide23

Thank You! Please contact Risk Management with any questions