Risk Management Program in Durham VA Order Instructions: The facility is Durham VA in North Carolina
The Session Long Project for this course is to evaluate and critique a health care facility you are familiar with and compare it to the general principles and standards for quality assurance presented in this course.
In the earlier modules, you identified a health care facility for the subject of the SLP and presented a description of the facility and its quality assurance program. You also critiqued the facility’s Continuous Quality Improvement program, the Utilization Management Program, and Case Management Program.
In this module, you will discuss and critique the subject facility’s Risk Management program.
SLP Assignment Expectations
For this module you are to complete the following tasks in a 4- to 5-page paper:
•Describe and discuss the facility’s Risk Management program. Do you feel their Risk Management program is adequate?
•Compare and critique the subject facility’s Risk Management program to that of a model facility and whether the facility adheres to the recognized standard for risk management.
•Identify areas for improvement in the facility’s Risk Management program, if any, and any recommendations you think should be implemented to lower risks in the facility. Give valid reasons for your answer.
Risk Management Program in Durham VA Introduction
Risk management programs were initially developed to reduce the incidents of malpractice lawsuits. However, risk management programs have evolved to a higher level of sophistication and are not designed to reduce preventable injuries and accidents and, of course, minimize financial severity of claims.
An effective risk management program usually operates on 18 bases to improve the quality of care by eliminating or minimizing the number of accidents or medical errors that occur in a health facility.
Risk management programs should include the following elements:
•A grievance or complaint procedure which is processed, investigated and resolved in a timely manner
•Collection of data related to all negative healthcare outcomes that occur with in the health facility
•A medical care of the evaluation process which will periodically assess the quality of medical care provided in the facility
•Educational programs for staff which focuses on patient safety, medical injury prevention, legal aspects of patient care, problems with communicating and establishing rapport with patients
Although risk management programs should include the elements mentioned above they should also carry out the following functions:
•Prepare incident reports
•Evaluate the frequency and severity of incident exposure
•Develop and implement corrective actions to reduce risk and exposure to liability
•Develop policies and procedures to ensure early intervention and sympathetic care after an accidental injury to a patient
•Identify and investigate specific incidents of patient injuries and provide appropriate intervention if required
•Train and educate all staff, including clinicians, to minimize exposure and lower risks
•Maintain a public relations program
And some health-care facilities, the risk management program also includes a health risk assessment program. The purpose of this program is to educate staff and patients about the connection between lifestyle habits and disease with an outcome of lowering potential risk factors for disease. In other words, and effective health risk assessment program will lower individual health risks.
Risk Management Program in Durham VA Required Reading
Anand, U. A., Asif, A. S., Muhil, S., & Thomas, L. (2015). Healthcare risk evaluation with failure mode and effect analysis in established of the new dialysis unit. The Journal of National Accreditation Board for Hospitals & Healthcare Providers, 2(1), 15.
Asefzadeh, Saeed; Yarmohammadian, Mohammad H.; Nikpey, Ahmad; Atighechian, Golrokh, (2013).Clinical risk assessment in the intensive care unit. International Journal of Preventive Medicine4(5), 592 – 598.
Aurel Oiuga, Aurel, McGuir, Marua J., (2014). Adherence and health care costs. Risk Management and Healthcare Policy, 7, 35-44.
Farokhzadian, J., Nayeri, N. D., & Borhani, F. (2015). Assessment of clinical risk management system in hospitals: An approach for quality improvement. Global Journal of Health Science, 7(5), 294-303. Retrieved from http://search.proquest.com/docview/1667361206?accountid=28844
Fibuch, Eugene, Ahmed, Arif, (2014). The Role of Failure Mode and Effects Analysis in Health Care. Physician Executive40(4), 28-32.
Murphy, J. S., Reid, M., Ali, A., Harrington, L., & Sandel, M. (2015). Applying Failure Modes and Effects Analysis to Public Health Models: The Breathe Easy at Home Program. Frontiers in Public Health Services and Systems Research, 4(4), 29-35.
Rodríguez-Pérez, J. & Peña-Rodríguez, M. E. (2012). Fail-safe FMEA: Combination of quality tools keeps risk in check. Quality Progress, 45(1), 30-36.
Shea, M. J. (2014). Assessing a risk management programme. Pharmaceutical Technology Europe, 26(9), 48-50. Retrieved from http://search.proquest.com/docview/1625580328?accountid=28844
Shirouyehzad, H., Dabestani, R., & Badakhshain, M. (2011). The FEMA approach to identification of critical failure factors in ERP implementation. International Business Research, 4(3), 254-263.
Stewart, A. (2011). Risk management: The reactive versus proactive struggle. Journal of Nursing Law, 14(3/4), 91-95.
Risk Management Program in Durham VA Optional Reading
Fassett, W. E. (2011). Key performance outcomes of a patient safety curricula: Root cause analysis, failure mode and effects analysis, and structured communication skills. American Journal of Pharmaceutical Education, 75(8), 1-5.
Websites
Richards, E.P., & Rathbun, K.C. (n.d.). Chapter 2 – Risk Management. Medical Risk Management. Retrieved from the web November 2012 at http://biotech.law.lsu.edu/Books/aspen/Aspen-Chapter-2.html
Risk Management Program in Durham VA Sample Answer
Risk management Program in Durham VA
The risk management program used to establish a culture of safety within the organization is the Root Cause Analysis program. The facility has employed a full time patient safety manager who is responsible for conducting investigations on all adverse events at a local level. The safety manager rates all the adverse incidences reported in the organization using two criteria; a) harm in terms of catastrophic to minor and b) probability in terms of frequency and remote. In this healthcare facility, harm is rated using four tier scale including a) catastrophic which includes all events that leads to permanent loss of function or death; b) major level which is associated with permanent lessening of patients body function; c) moderate level which includes lengthened stay or increased level of care and d) Minor which is associated with mild injuries. The probability of the event is rated as frequent, occasional, uncommon and remote (Durham VA, 2015).
The aim or RCA program is to identify the adverse events, why it occurred and ways to prevent it from occurring again. The Durham VA has embraced a culture of safety that is not based on punishment but on prevention. The RCA team conducts an investigation on the functioning of patient care systems using the Human Factors Engineering (HFE) approaches with the aim of supporting human performance. The RCA team includes representatives from frontline clinical staff as they are strategically placed to identify clinical adverse events and plausible solutions (Mills et al., 2008).
The RCA strategy is adequate because it includes analysis of human factors, environment factors, the healthcare facility processes and systems. In addition, the process also involves an in-depth analysis of the cause –effect system as it leads to an identification of risks and its potential contribution. The method follows a pre-specified protocol that begins with data collection, reconstruction of the events in question by recording the perceptions from participant’s interviews. The identified multi-disciplinary team then analyzes the sequence of events that led to the event with the aim of identifying active errors that led to the incidences, systematic identification of the causes and comprehensive analysis of the latent errors. The ultimate aim for RCA is to prevent more harm from occurring in the future by eliminating the latent errors that underlies the adverse events (Durham VA, 2015).
For instance, a case scenario where the patient underwent a cardiac procedure that was to be done in another patient who had similar surnames. If traditional risk management strategy was to be used on this patient, then the analysis would have primarily assigned the blame to the healthcare provider on duty, probably the nurse who prepared the patient for the procedure without cross checking for the second time. However, the facility applied RCA strategy which led to the identification of 17 distinct errors that ranged from organizational factors (the department used error prone system that identified patient using their surnames and not patient identification number), work environment factors (the nurse and neurosurgeon did not cross check the names of the patient) among others. Through RCA, the healthcare facility has implemented crucial systematic changes that reduce the risk of similar events in the future (Durham VA, 2015).
Compare and critique subjects risk management program with FMEA
The RCA process is a risk management tool that effectively identifies strategic preventive measures, a process that is part of building the culture of safety. Using this strategy, the basic and contributing causes are identified through similar approaches such as the diagnosis of disease with the aim of treating the disease and preventing it from re-occurring. This process involves multidisciplinary experts from the front line who are familiar with the situation. The team continually digs deeper by evaluating the cause and effect at each level. Through this process, they are able to identify safety measures that should be changed or integrated into the healthcare facility (Mills et al., 2008).
RCA differs considerably from FMEA. For instance, FMEA is a proactive risk management whereas RCA manages risk at their occurrence. RCA is structured in analytic methodology that is used to evaluate the underlying contributions to adverse events and its implementation. On the other hand, FMEA is a structured analytic method used primarily to identify the appropriate basis in which the process can reduce the likelihood of occurrence to such failure. However, the main advantage of the RCA process is that it is as impartial as possible (Anand, Asif, Muhil, & Thomas, 2015).
In addition, the risk management program adhere to the recognized standards of risk management in that it facilitates the preparation of reports, evaluates frequency and severity of the adverse effects, help to develop as well as to implement strategic corrective measures that will reduce exposure to similar liability. The program also improves the process of investigating specific incidents and in developing specific policies and procedures and to give appropriate intervention where necessary. This risk management program helps in educating staff and patients regarding the connection between disease and lifestyle habits with the aim of lowering individual and healthcare risks (Durham VA, 2015).
Areas for improvement and recommendations
RCA is a valuable technique used to understand the root cause of adverse effects. However, the program is not very effective in complex systems because they normally do not have a single root cause. This is because failures of a complex system emerge from confluence occurrences and conditions associated with the pursuit of success. Each of the elements is important but causes sufficient harm when combined jointly in a specific sequence. Therefore, this calls for an approach that involves both technological and organizational influences. It is important to understand that human performance and variability is not intrinsically coupled with causes and it requires diverse components complexity is systems that do not only identify system vulnerabilities but also augment system resilience (Mills et al., 2008).
There are various systematic risk management programs that can be used effectively, but the evidence based program is the FMEA. FMEA is recommended because it is a logical risk management program that is structured in a way that it effectively evaluated processes and reveals healthcare areas that needs to be improved. One most critical advantage of this system is its ability to make early identification of single failure points or system interface that hinders success and negatively impact on patient safety (Fibuch and Ahmed, 2014).
Risk Management Program in Durham VA References
Anand, U. A., Asif, A. S., Muhil, S., & Thomas, L. (2015). Healthcare risk evaluation with failure mode and effect analysis in established of the new dialysis unit. The Journal of National Accreditation Board for Hospitals & Healthcare Providers, 2(1), 15.
Durham VA. (2015). Risk management and compliance service. Retrieved from https://www.va.gov/oal/about/rmc.asp
Fibuch, E., and Ahmed, A.(2014). The Role of Failure Mode and Effects Analysis in Health Care. Physician Executive40(4), 28-32.
Mills, P.D., Neily, J., Kinney, L.M., Bagian J., and Weeks, W.B. (2008). Effective interventions and implementation strategies to reduce the adverse drug events in Vthe eterans Affairs (VA) system. Qual. Saf. Healthcare 17; 37-46 doi:10.1136/qshc.2006.021816
