create a brief case study presentation

Case study link

https://psnet.ahrq.gov/web-mm/undetected-foreign-o…

Instructions:

-Conduct research on the case utilizing the risk assessment questions (slide 5)-Conduct the root cause analysis using a fish bone diagram-Actions recommended by the author(s) of the case discussion to prevent a similar eventfrom occurring in the future.

Risk Management in Healthcare
Brief Overview
What is Risk and Risk Management
Domains of Risk and Examples of Healthcare Risks
Steps in Risk Management
Risk Identification
Risk Evaluation
Implementing Strategies to Reduce Risk
Healthcare Laws, Regulations, and Programs
What is a Risk?
“Probability or threat of damage,
injury, liability, loss, or any other
negative occurrence that is caused by
external or internal vulnerabilities, and
that may be avoided through
preemptive action.”
Source: http://www.businessdictionary.com/definition/risk.html
What is Risk Management?
“The discipline by which an organization
identifies, assesses, controls, measures and
monitors various risks and opportunities for the
purpose of achieving the entity’s strategic and
financial objectives”
Source: https://www.soa.org/globalassets/assets/Files/Newsroom/news-erm-fact-sheet.pdf
Risk Assessments help answer the following questions:
What can go
wrong?
Is there a need
for action?
How can it go
wrong?
Why does it go
wrong?
Who does it
affect?
How often does it
go wrong? What
is the extent?
Source: http://www.dbhds.virginia.gov/library/quality%20risk%20management/qrm-a%20simple%20approach%20to%20risk%20assessment.pdf
Identify
What? How?
Steps in Risk
Assessment
Review/
Evaluate/
Monitor
Program
Risk
Management
Is it
working?
Evaluate
Why? How
often? Who?
Action
Needed?
Develop
and
Implement
Strategies
Risk
Identification
Why is it important for organizations
to identify issues?
What must organizations do to identify
issues within their system?
Surface
Reality
Methods of Risk Identification
1. Brainstorm
2. SWOT Analysis
3. Eight Risk Domains
4. Root Cause Analysis (RCA)
Source : https://www.ashrm.org/sites/default/files/ashrm/ERM-White-Paper-8-29-14-FINAL.pdf
Brainstorm
• Gather information – Interviews, staff/departmental meetings,
surveys or review quality reports to identify problem areas
• Create a list – List out what issues the organization is facing
SWOT Analysis
• Identifying Strengths,
Weaknesses, Opportunities
and Threats.
• To Remember:
• Strengths and Weaknesses are
usually internal to the organization.
• Opportunities and Threats are
usually external to the organization.
Strengths
Weaknesses
SWOT
Opportunities
Threats
Eight Risk Domains
in
Risk Management
Eight Risk Domains
Can you think of risk examples in
healthcare for each of these
domains?
Root Cause Analysis
The dictionary defines “root cause”
as the fundamental cause, basis, or
essence of something, or the source
from which something derives.
Root cause analysis is a systematic
process for identifying “root causes”
of problems or events and an
approach for responding to them.
Source: https://www.thehealthcompass.org/how-to-guides/how-conduct-root-cause-analysis
Goals of the Root Cause Analysis (RCA) is to identify:
1
2
3
4
• What happened?
• Why it happened?
• How it happened?
• Actions to prevent reoccurrence of problems
Source: https://www.thehealthcompass.org/how-to-guides/how-conduct-root-cause-analysis
Steps to Identify Root Causes
1
2
3
4
5
6
• Define the problem.
• Gather information, data and evidence.
• Identify all issues and events that contributed to the problem.
• Determine root causes.
• Identify recommendations for eliminating or mitigating the reoccurrence of problems
or events.
• Implement the identified solutions
Source: https://www.thehealthcompass.org/how-to-guides/how-conduct-root-cause-analysis
Root Causes Analysis Methods
Fault Tree
Analysis
Five Whys
Tool
Pareto
Analysis
Fishbone
Diagrams
Fault Tree Analysis
• Refer to Video:
https://www.youtube.com/watch?v=aVfMsPOKr
ak
• We will not be using this tool in class and will
not be covering this tool in depth. However, it is
important for you to know what it is and what it
looks like.
• Refer to the image on the right for an example
of what a fault tree analysis looks like:
Source: http://asq.org/quality-progress/2002/03/problem-solving/what-is-a-fault-tree-analysis.html
The Five Whys Method
The Five Whys is a
simple problemsolving technique
that helps to get to
the root of a problem
quickly.
Five Whys strategy
involves looking at
any problem and
drilling down by
asking: “Why?” or
“What caused this
problem?”
The goal of this tool is
to prompt another
“Why” till you get to
the root of the
problem.
Source: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/FiveWhys.pdf
Example of the Five Whys Method (CMS)
Problem statement – your car gets a flat tire on your way to work.
1. Why did you get a flat tire?
• You ran over nails in your garage
2. Why were there nails on the garage floor?
• The box of nails on the shelf was wet; the box fell apart and
nails fell from the box onto the floor.
3. Why was the box of nails wet?
• There was a leak in the roof and it rained hard last night.
Source: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/FiveWhys.pdf
Pareto Analysis
• Is a useful technique for prioritizing problem-solving work, so that the first
piece of work you tackle simultaneously resolves the greatest number of
problems.
• Refer to video: The Pareto Principle
20% Effort
Source: http://www.free-management-ebooks.com/news/pareto-analysis/
80%
Results
Steps to do a Pareto Analysis
1
2
3
4
5
• List problem areas
• Identify root cause for each problem
• Score each problem in terms of importance
• Group those with same root cause
• Fix problems with highest score
Source: http://www.free-management-ebooks.com/news/pareto-analysis/
Fishbone Diagrams
1
2
3
4
• Also known as a cause and effect analysis/ Ishikawa diagram
• Ideal problem solving tool for management
• Helps managers and leaders brainstorm root causes to issues
• Provides a clear visual by grouping organizational issues into
categories
Source: https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdf
Fishbone Diagram Example (CMS)
Source: https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdf
Risk Evaluation
What to look for when evaluating risks:
1
2
3
• Look for repetitions and group them. Have similar risks been
brought up before by multiple units?
• Look for risks that are cost-effective and easy to implement
• Look for risks that already have solutions and strategies in place
and make sure that the ones in place actually WORK.
Source : https://www.ashrm.org/sites/default/files/ashrm/ERM-White-Paper-8-29-14-FINAL.pdf
Risk Score
– Not an exact measure. However, it is still helpful to sort and organize risks.
– Tool used by managers and administrators to gain a better understanding
of the organization’s risk.
– Doing this allows them to better understand which risks need to be
prioritized.
– “A Likert scale ranking of one (1) to five (5) is most often used. With 1
being the lowest, least likely to occur, or least impactful. Using the range of
1 to 5 for both dimensions the highest ranking is 25.”
Sources : https://www.ashrm.org/sites/default/files/ashrm/ERM-White-Paper-8-29-14-FINAL.pd
http://www.dbhds.virginia.gov/library/quality%20risk%20management/qrm-a%20simple%20approach%20to%20risk%20assessment.pdf
Risk Score Formula
– “Likelihood also referred to as frequency or probability, refers to the number
of times an adverse event or occurrence (a risk) will happen. This dimension
is expressed in terms of a number or ratio. “
– “Impact also referred to as severity, refers to the anticipated outcome of the
risk if it occurs. Impact is most often referenced in financial terms (dollars $)
and can also be referred to as “vulnerability”, “consequences”. “
Likelihood
X
Impact
Source : https://www.ashrm.org/sites/default/files/ashrm/ERM-White-Paper-8-29-14-FINAL.pdf
=
Risk Score
Risk Map
– Also known as risk matrix or heat map
– Can also be referred to as a heat map
due to the colors that are used.
– X axis is the likelihood.
– Y axis is the impact.
Source : https://www.ashrm.org/sites/default/files/ashrm/ERM-White-Paper-8-29-14-FINAL.pdf
Risk Map
Low Risk (Green)
• Are usually Quick and easy actions. The can be implemented immediately.
Moderate Risk (Yellow)
• Actions are usually implemented as soon as possible but no later than next 60 – 90 days.
High Risk (Orange)
• Actions are usually implemented as soon as possible but no later than 30 days.
Extreme Risk (Red)
• Requires urgent action. Immediate corrective action needed.
Source: http://www.dbhds.virginia.gov/library/quality%20risk%20management/qrm-a%20simple%20approach%20to%20risk%20assessment.pdf
Implementation
Strategies to
Reduce Risk
Implementation Strategies to Reduce Risk
– Review this website for examples
and definitions of each of these
implementation strategies: Risk
Management Strategies
Source: https://www.theamateurfinancier.com/blog/risk-management-
Low Likelihood
High Likelihood
Low Impact
Retain
Reduce
High Impact
Transfer
Avoid
Healthcare Laws,
Regulations, Programs
and Organizations
Joint Commission on Accreditation of Healthcare
Organization (JCAHO)
– Founded in 1951
– Independent, non-profit organization
– It is an accrediting body that aims to maintain the highest standards in
healthcare organizations and improve their process and performance.
– Consists of surveyors (including doctors, nurses and other healthcare
workers) who are trained to inspect and survey various healthcare
facilities.
– They look to see if the healthcare organization is maintaining and
following proper protocol in safety and quality.
– In order for an organization to be accredited, they must pass the on-site
survey that is conducted every 3 years. For clinical laboratories, the onsite survey is conducted every 2 years.
– As of 2018, 77% of the nation’s hospitals have been accredited by JCAHO.
Source: https://www.jointcommission.org/
Sentinel Event (JCAHO)
A sentinel event is a patient safety event (not
primarily related to the natural course of the
patient’s illness or underlying condition) that
reaches a patient and results in any of the following:
• Death
• Permanent harm
• Severe temporary harm
Source: https://www.jointcommission.org/
Goals of the Sentinel Event Policy (JCAHO)
1. To have a positive impact in improving patient care, treatment,
and services and in preventing unintended harm
2. To focus the attention of a hospital that has experienced a
sentinel event on understanding the factors that contributed to
the event (such as underlying causes, latent conditions and
active failures in defense systems, or hospital culture), and on
changing the hospital’s culture, systems, and processes to
reduce the probability of such an event in the future
3. To increase the general knowledge about patient safety events,
their contributing factors, and strategies for prevention
4. To maintain the confidence of the public, clinicians, and
hospitals that patient safety is a priority in accredited hospitals
Source: https://www.jointcommission.org/
Centers for Medicare and Medicaid Services (CMS)
– “The Centers for Medicare & Medicaid Services (CMS) is part of the
Department of Health and Human Services (HHS). CMS administers programs
including: Medicare, Medicaid, the Children’s Health Insurance Program
(CHIP), and the Health Insurance Marketplace” (CDS, 2020).
– They service over 100 million people.
– Their goal is to provide high-quality care that is affordable.
– CMS requires healthcare organizations to have proper risk management and
assessment techniques in place. Especially with CMS sensitive material.
– Patient Safety Example: If hospital has a high rate of hospital-acquired
infections compared to 75% of hospitals in the nation, CMS will provide less
reimbursement to this hospital.
– Fact: The Hospital Acquired Condition Program was developed with the aim
to improve patient’s health and quality of care. With this program, Medicare
saves about $350 million per year.
Sources: https://cds.ahrq.gov/cdsconnect/org/centers-medicare-and-medicaid-services, https://www.usa.gov/federal-agencies/centers-for-medicare-and-medicaid-services,
https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Downloads/RMH-Chapter-14-Risk-Assessment.pdf
Occupational Safety and Health Administration (OSHA)
– Signed by President Nixon in 1970.
– Was created by Congress to ensure proper and safe
working conditions for workers.
– These are enforced through training, education,
resources, and outreach.
– Through this program and its efforts, deaths and injuries
to workers have significantly decreased by over 65%.
– Workplace injuries and deaths cost American employers
over $59 billion every year (Worker’s Comp).
Sources: https://www.osha.gov/aboutosha
https://www.osha.gov/Publications/all_about_OSHA.pdf
Emergency Medical Treatment and Labor Act (EMTALA)
– Enacted in 1986 by Congress.
– This Act ensures that the public is ensured access to care
and treatment in an emergency regardless of their ability
to pay for the services provided or status of insurance.
– All hospitals with an Emergency Department are
required to follow the policies under EMTALA.
– Hospitals could receive up to a $50,000 penalty for
refusing or not providing service to a patient.
– For hospitals with less than 100 beds, a penalty of
$25,000 can be imposed.
Source: https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index
https://www.acep.org/life-as-a-physician/ethics–legal/emtala/emtala-fact-sheet/
References
http://www.free-management-ebooks.com/news/six-step-problem-solving-model/
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/FiveWhys.pdf
http://www.free-management-ebooks.com/news/cause-and-effect-analysis/
http://www.free-management-ebooks.com/news/cause-and-effect-analysis/
https://conceptdraw.com/a2300c3/preview
https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781118364727.ch29

7 Steps to a Fishbone Diagram and to Identifying Those Causes

https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdf
http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyCodeBlue.aspx
http://app.ihi.org/LMS/Content/515875cb-65a5-4f20-911d-3e5aeefeaa4f/Upload/Case%20study.pdf
http://www.businessinsider.com/nine-steps-to-effective-business-problem-solving-2011-7
https://executiveeducation.wharton.upenn.edu/thought-leadership/wharton-at-work/2015/06/identify-the-real-problem
https://www.thehealthcompass.org/how-to-guides/how-conduct-root-cause-analysis
https://des.wa.gov/services/risk-management/about-risk-management/enterprise-risk-management/root-cause-analysis
https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index
https://www.acep.org/life-as-a-physician/ethics–legal/emtala/emtala-fact-sheet/
https://www.osha.gov/aboutosha
https://www.osha.gov/Publications/all_about_OSHA.pdf
https://cds.ahrq.gov/cdsconnect/org/centers-medicare-and-medicaid-services
https://www.usa.gov/federal-agencies/centers-for-medicare-and-medicaid-services,
https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Downloads/RMH-Chapter-14-Risk-Assessment.pdf
https://www.jointcommission.org/
https://www.theamateurfinancier.com/blog/risk-management-strategies
http://www.dbhds.virginia.gov/library/quality%20risk%20management/qrm-a%20simple%20approach%20to%20risk%20assessment.pdf
https://www.ashrm.org/sites/default/files/ashrm/ERM-White-Paper-8-29-14-FINAL.pdf
https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdf
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/FiveWhys.pdf
http://asq.org/quality-progress/2002/03/problem-solving/what-is-a-fault-tree-analysis.html
https://www.soa.org/globalassets/assets/Files/Newsroom/news-erm-fact-sheet.pdf
http://www.businessdictionary.com/definition/risk.html
https://www.jointcommissioninternational.org/-/media/jci/idev-imports/sentinel_event_policy1.pdf?db=web&hash=36C66D8155F4FD9AEEF0E22392019284