Risk and Safety Management: A Case Study

Risk and Safety Management:

A Case Study

Stacy Norris, BSN, RN

Midas+ Infection and Risk Product Manager

Amanda DeGraeve

Midas+ Care Management Product Manager

Objectives

• Discuss applicable standards and regulations for

safety reporting of events

• Share a sample Risk Event and its life cycle

• Demonstrate how technology supports Risk Event

management

Basic Principles of Risk Event

Management

Basic Principles of Risk Event

Management

Risk Event Notification and

Response Process

Risk event occursUnit Manager is

notified

Electronic forms is completed for the

event

Unit Manager alerted via email

that an incident has occurred and needs

attention

Unit Manager begins investigating

the event

Unit Manager enters findings into the secure shared

database

Review is completed and routed to Risk Management

Risk Manager reviews information received and makes final level of harm and significance

determination for event

Further investigation

needed?Yes No

If additional managers need to

be included in investigation and makes additional

referrals as appropriate

Sentinel Event / Immediate jeopardy?

Based on new information, Risk Manager

deems incident a Sentinel Even

or needing Quality Review

for potential RCA or formal Case Review

No Yes

Event classified and closed by Risk

Manager

Qualifying events will be

reported through PSO

Event reporting process

Once all review is complete by Risk and Quality Management, available data should

be aggregated, reviewed and

appropriate actions are to be

implemented for identified

opportunities for improvement

Data aggregation that has occurred

will be used in reporting by Risk Management and

Safety Services

ACKNOWLEDGE ACT

ANALYZE

AGGREGATEACT ANALYZE

Affordable Care Act

• “We proposed to require, under new paragraph (a)(2)(i)(B), that for

plan years beginning on or after January 1, 2017 a QHP issuer that

contracts with a hospital with greater than 50 beds must ensure that

the hospital implements a comprehensive person-centered discharge

program to improve care coordination and health care quality for each

patient. We noted that use of a data-driven approach, analytic

feedback, and shared learning to advance patient safety, such as

working with a Patient Safety Organization (PSO), are essential to

implementing meaningful interventions to improve patient health care

quality.”

– Final Rule posted on March 8, 2016:

https://www.federalregister.gov/articles/2016/03/08/2016-

04439/patient-protection-and-affordable-care-act-hhs-notice-of-

benefit-and-payment-parameters-for-2017#h-8

Where Does the Data Go?

• Patient Safety

Organization (PSO)

• Patient Safety

Organization Privacy

Protection Center

(PSOPPC)

• Network of Patient

Safety Databases (NPSD)

– No data transmitted from

PSOPPC due to data integrity

issues

Case Study: Risk Event

Eighty-six-year-old male patient, Dan Arcos, was admitted to

Midas Health with sepsis. He was assessed to be a fall risk

during the admission process.

No signage was placed on his door alerting staff to the fall

frequent check protocol and no bed alarm was implemented.

On his third day of admission, he fell while attempting to walk

unassisted to the bathroom. The nurse found him on the floor

and assessed him to have a right elbow skin tear and

hematoma. The physician was notified. The nurse submitted

the event via the Remote Data Entry process to the Risk

Management Department.

Risk Event Notification and

Response Process

Risk event occursUnit Manager is

notified

Electronic forms is completed for the

event

Unit Manager alerted via email

that an incident has occurred and needs

attention

Unit Manager begins investigating

the event

Unit Manager enters findings into the secure shared

database

Review is completed and routed to Risk Management

Risk Manager reviews information received and makes final level of harm and significance

determination for event

Further investigation

needed?Yes No

If additional managers need to

be included in investigation and makes additional

referrals as appropriate

Sentinel Event / Immediate jeopardy?

Based on new information, Risk Manager

deems incident a Sentinel Even

or needing Quality Review

for potential RCA or formal Case Review

No Yes

Event classified and closed by Risk

Manager

Qualifying events will be

reported through PSO

Event reporting process

Once all review is complete by Risk and Quality Management, available data should

be aggregated, reviewed and

appropriate actions are to be

implemented for identified

opportunities for improvement

Data aggregation that has occurred

will be used in reporting by Risk Management and

Safety Services

ACKNOWLEDGE ACT

ANALYZE

AGGREGATEACT ANALYZE

Midas+ Care Management

Suggested Data Flow

Addition of the Risk Event Episode

Mapping User-defined Terms to

AHRQ Common Format Terms

Creation of the PSO Event via

Virtual Worklist Target

PSO Event

SmarTrack Reporting

ReporTrack Documents

Midas+ Juvo

Common Formats v2.0

• Public comment closed on May 9, 2016

• Target dates, subject to change:

– Technical specifications – January 2017

– Submission of events to PSOPPC using 2.0 –

August 2017

• Versions 1.2 and 2.0 will be supported

Noteworthy changes in v2.0

• Two tiers

– National and Local

• Generic forms (HERF, PIR, SIR) combined

• Local only:

– VTE, Blood and Device

• Surgery and Anesthesia separated into two forms

• HAI removed – was duplicative with NHSN

reporting

Resources

• AHRQ website:

http://www.pso.ahrq.gov

• PSO Privacy Protection Center:

https://www.psoppc.org

• Midas+ Clients Only website:

https://www.midasplus.com

Thank you for attending.

Any questions?

Stacy Norris, BSN, RN

Midas+ Infection and Risk Product Manager

stacy.norris@xerox.com

Amanda DeGraeve

Midas+ Care Management Product Manager

amanda.degraeve@xerox.com