Contributions to Adverse Event

Transcription

1 Carla s Care Chris Hoedt, MPH, MMSc (EVMS MD Candidate 2013) Erik Johnson (EVMS MD Candidate 2013) Kelly Johnson (EVMS MD/MPH Candidate 2015) Ashley Branch (Sentara Heart Hospital Research Assistant) Michele Kibler (VCU Sentara Healthcare Administrative Fellow)

2 Overall Process Map

3 Overall Process Map

4 Contributions to Adverse Event

5 System Rules So long as they follow all regulations and laws, each clinic and hospital should independently develop their protocols to match established best practice, but with adjustments due to patient population and limitations of the facility (for example, staffing and financial constraints). The clinics should be free to modify and test their protocols. To encourage innovation, facilities that excel in both patient satisfaction and medical outcomes should be financially rewarded. This system recognizes that patients interact with the system in unpredictable ways and cannot be mechanized by the institution of rigid, inviolate protocols. For example, Carla s ideal health care system acknowledges that daytime appointments frequently inconvenience patients. Each clinic would have operating hours optimized for patient attendance, for example: evening appointments.

6 Ideal Process Map

7 Ideal Process Map

8 Processes to Improve Patient-centered availability of appointments at the dialysis clinic: Within 2 years we will have changed our hours of operation such that 95% of our patients report they have no difficulty scheduling an appointment that conveniently fits within their schedule. Integration between the emergency department and other clinics: By the end of 1 year we [the ED] will have 20% of local clinics participating in a program that notifies the clinics when one of their patients visits the ED, and relates to the clinics any resulting changes in medication or conditions to monitor. Lack of automatic alert for critical lab values in the hospital: Within 3 months we will leverage our EMR system to reduce by 50% the response time to critical lab values of our patients.

9 Suggested Measures Patient-centered availability of appointments at the dialysis clinic Outcome measure: Patients reporting that appointments fit conveniently into schedule Process measures: Rate of completion of satisfaction questionnaire, patients arriving late for appointments, patients missing appointments Balancing measures: Operating costs, employee job satisfaction questionnaire Integration between the emergency department and other clinics Outcome measure: Rate of participation of local clinics Process measures: Clinics adopting use of EMRs, rate of notifications that are lost or go unnoticed, rate of notifications that are never sent, reported incidents of a change in care due to information received from the ED, clinic satisfaction questionnaire Balancing measures: Operating costs, person-hours spent maintaining lists of clinic patients Lack of automatic alert for critical lab values in the hospital Outcome measure: Time between critical lab value obtained and treatment begun Process measure: Physicians reporting active notification of critical lab values Balancing measures: Cost of implementation, staff complaints about loss of chart flow

10 Recommended Changes 1. Enhanced communication between hospital and satellite locations, especially those without EHR Fax system where hospital EHR automatically sends copies of all pt records to PCP offices w/o EHR & PCP faxes copies of all records to central EHR warehouse to be scanned and added to EHR Follow-up sheets included in faxes for lab values, etc. 2. On-call Nutritionist and phone/web appointments 3. Auto-alert with EHR Every time the pt chart is accessed abnormal lab values and notes will appear, until appropriate treatment documented or normal labs 4. Evening appointments during the week and some weekend hours 5. Removal of the 15 minutes late policy Addition of Emergency Appointment Time Slots

11 Testing Efficacy of Changes 1. Will enhanced communication improve patient treatment adherence and follow-up between locations? Codes assigned to communications for response, no response at all, response after Clinical Coordinator calls to correct no response Administrative Statistician with IT knowledge hired to run pilot program out of central hospital. 3 month normal, 3 month fax program 3 paper clinics (site managers at each) & 3 EHR clinics 2. Does nutritionist access improve patient diet changes & increase patient satisfaction? Clinical Research Coordinator a) 3 months - surveys patients seeing nutritionist if they would use phone/web option if nutritionist not available over scheduling appointment and follows up with call on diet change each month b) Next 3 months - post phone/web nutritionist meeting, similar survey given to patients and in-person patients get old survey

12 Testing Efficacy of Changes 3. Does auto-alert improve response time to critical labs and conditions? Time recorded from when critical value known, until it has been acted on. The EHR in the hospital would make this fairly simple to monitor by IT department for 3 months without alerts and then 3 months with alerts. 4. Do evening & weekend appointments reduce missed & late appointments? IT codes for missed and late appointments, which office assistant inputs when patients arrive. a) 3 months no added times and 3 months with added times 5. Do emergency appointment slots reduce rescheduling and wait times? IT codes reason of rescheduled appointments, targeting late & missed appointment patients that office assistant can input; 3-3 months Research assistant checks patient wait time, even late patients a) Allows late & emergency patients better access. Helps physicians stay on schedule if behind & slot is not filled (aka buffer time)

13 Challenges & Obstacles Challenges to overcome Staff unwilling to work atypical hours Financial constraints HIPAA regulatory requirements Coordinating care efforts and information flow between unrelated medical facilities Lack of universal adoption of EMR Incompatibility of EMR systems Comfort with the status quo Methods to overcome resistance Test changes on small scale before implementation to demonstrate effectiveness Determine revenue lost due to missed appointments Poll patient satisfaction and trust in clinic or hospital before and after changes tested Ensure method of medical information transmission is HIPAA compliant prior to testing Provide advantage to clinics that adopt EMRs (ex: some record sharing with hospital) Offer shift differentials or bonuses to staff willing to work atypical hours Point-out PR benefits of becoming a possible magnet facility

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