Risk Management, Quality Improvement, and Patient Safety Rights

Question 1

What is quality?

Answer 1

Doing the right thing at the right time in the right way to the right person AND having the best possible results

Question 2

What are the 6 QI aims?

Answer 2

1. safe
2. effective
3. efficient
4. equitable
5. timely
6. patient-centered

Question 3

What is Risk Management (RM)?

Answer 3

Processes to identify, evaluate, and control risk

Minimizes negative outcomes

Question 4

What’s the difference between QI and RM?

Answer 4

• QI – making sure “good things” happen
• RM – reducing the likelihood that “bad things” will happen

Question 5

The technical term for “bad things” is ______

Answer 5

adverse events

Question 6

Darling v. Charleston Community Memorial Hospital

Answer 6

• Concept of charitable immunity is challenged
• opens hospitals to liability via negligence

Question 7

What is an Enterprise Risk Management (ERM) approach?

Answer 7

Process that focuses on identifying and eliminating financial impact and volatility of a risk portfolio

Question 8

Who governs RM?

Answer 8

state law

Question 9

Steps in a RM program (4)

Answer 9

1. Risk identification
2. Risk evaluation
3. Strategic risk response and implementation
4. Review, evaluate,e and monitor whether objectives are being met

Question 10

What is Risk identification?

Answer 10

• Systematic means of identifying potential risks.
• Requires understanding of facility’s business, legal, organizational, and clinical components

Question 11

What is risk evaluation and assessment?

Answer 11

• Identifying which risks should be proactively addressed and which risks are lower in priority

Question 12

What is strategic risk response and implementation?

Answer 12

• Applying risk control and risk financing techniques to determine how risk should be treated

Question 13

Tools of Risk Management: A claims management program

Answer 13

requires knowledge of insurance polices

Question 14

Tools of Risk Management: Incident Reporting

Answer 14

Helps to identify and respond to adverse events and occurrences inconsistent with standard of care

Question 15

Incident documentation should be _____, concise, and present only the facts

Answer 15

objective

Question 16

What is the Role of the Health Record in Risk Management?

Answer 16

Determine deviation from the standard of care

Question 17

The JC’s def of sentinel events

Answer 17

A patient safety event not primarily related to the natural course of a patient’s illness or underlying condition that reaches the patient and results in death or severe hardship/disability.

Question 18

Do incident reports go into the pt’s health record?

Answer 18

No, therefore, it is not subject to legal discovery

(NOTE: unless it results in pt death –> will show up in EHR).

Question 19

JC requires _____ for sentinel events if commissioned by JC

Answer 19

root cause analysis (RCA)

Question 20

Who develops definitions of sentinel events?

Answer 20

the organization

Question 21

National patient safety goals

Answer 21

yearly goals to improve pt safety

Question 22

JC Safety goals: requirements that support documentation (5)

Answer 22

• two pt identifiers
• final verification before invasive procedures
• read-back of verbal orders/results
• standardized abbreviations/acronyms
• improve the timeliness of reporting/test results

Question 23

Healthcare Research and Quality Act of 1999

Answer 23

• created AHRQ to develop and promote error-reducing strategies

Question 24

What does PSRO do? (1972)

Answer 24

Review the medical necessity of care

Question 25

IOM report: To Err is Human year

Answer 25

1999

Question 26

Office of the Nat’l Coordinator for Health IT(2004)

Answer 26

• coordinate nationwide efforts to advance the use of HIT and the electronic exchange of health info

Question 27

Crossing the Quality Chasm establishes “Six Aims” year

Answer 27

2001

Question 28

2005 Patient Safety and Quality Improvement Act (Patient Safety Rule)

Answer 28

AHRQ gets oversight responsibility for the creation and monitoring of PSOs

Question 29

What does the office of civil rights do?

Answer 29

enforces the confidentiality provision of the Patient Safety Rule

Question 30

ACA and National Quality Strategy

Answer 30

Quality initiatives to avoid costly mistakes, reward quality in a family-centered manner

Question 31

National Quality Strategy: QIN-QIOs

Answer 31

Work with providers, stakeholders, and Medicare beneficiaries to improve patient safety, reduce harm, engage patients and families, and improve clinical care at the local and regional levels.

Question 31

National Quality Strategy: BFCC-QIOs

Answer 31

Perform quality of care (medical case) and medical necessity reviews.

Question 32

Examples of Reporting of Quality and Patient Safety Measures (3)

Answer 32

• medicare care compare
• HealthGrades
• Leapfrog

Question 33

Patient Rights (6)

Answer 33

• care (and right to accept/refuse treatment)
• respect
• pt empowerment
• consideration of fam involvement
• ensure pt is edu abt their conditions
• informed abt health info use/disclosure

Question 34

Sources of Pt rights (6)

Answer 34

• AHA Patient Care Partnership
• JC Standards
• Medicare Conditions of Participation
• Affordable Care Act (ACA)
• State laws
• Organizational patient rights policies

Question 35

Rights of patients with mental illnesses

Answer 35

Involuntary civil commitment is permitted if the patient is a danger to self or others

Question 36

Pt seclusion

Answer 36

Involuntary confinement of a patient alone in a room or area; patient is prevented from leaving

Question 37

Pt restraint

Answer 37

Device or drug that restricts an individual’s movement; is not for diagnosis, treatment, or patient protection