HSA 406 Health Care Quality Management - Exam 2 - October 22, 2012

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Cause-and-effect or fishbone diagram
1.Cause-and-effect or fishbone diagram: QI Toolbox Technique used most often in root cause analysis is "Cause-and-Effect" or "Fishbone Diagram" ... This technique structures the root cause inquity and helps the investigators to be sure that they have examined the situation from all perspectives ... An investigational technique that facilitates the identification of the various factors (i.e., Manpower, Material, Methods, and Machinery) that contribute to a problem; also called a fishbone diagram.
(FMEA) 2.) Failure mode and effects analysis (FMEA) - A technique that promotes systems thinking, FMEA includes defining high-risk processes using flowcharts; identifying potential failure points in current processes; and scoring each potential failure by considering factors such as the frequency of failure, potential harm, and the likelihood that the failure will be detected before it reaches the patient. Potential failures with the highest criticality score become the focus of process redesign (Joint Commission 2008b)
Incident Report or Occurence Report 3.)Incident Report or Occurence Report: A structured data collection tool that risk managers use to gather information about potentially compensable events; also called an incident report.
Medication error 4.)Medication error: A mistake that involves an accidental drug overdose, an administration of an incorrect substance, an accidental consumption of a drug, or a misuse of a drug or biological during a medical or surgical procedure.
Incident Report or Occurence Report 5.) Incident Report or Occurence Report: A structured data collection tool that risk managers use to gather information about potentially compensable events; also called an incident report.
(PCEs) 6.) Potentially compensable events (PCEs): An occurrence that results in injury to persons in the healthcare organization or to property loss.
Risk 7.) Risk: A formal insurance term denoting liability to compensate individuals for injuries sustained in a healthcare facility.
Root-cause analysis 8.) Root-cause analysis: Analysis of a sentinel event from all aspects (human, procedural, machinery, material) to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence.
Bloodborne pathogen 9.) Bloodborne pathogen: Infectious diseases such as HIV and hepatitis B and C that are transported through contact with infected body fluids such as blood, semen, and vomitus.
Community-acquired infection 10.) Community-Acquired Infection: An infection that was present in a patient before he or she was admitted to a healthcare facility.
Flowcharts 11.) Flowcharts: An analytical tool used to illustrate the sequence of activities in a complex process.
(HAI) 12.) Healthcare-associated infection (HAI): An infection occurring in a patient in a hospital or healthcare setting in whom the infection was not present or incubating at the time of admission, or the remainder of an infection acquired during a previous admission.
Icons 13.) Icons: A graphic symbol used to represent a critical event in a process flowchart... Some Examples: Process Icons, Decision Icons, Predefined Process Icons, Connector Icons, Terminator Icons, Manual Input Icons, or Line Connector Icons.
(MDROs) 14.) Multiple drug-resistant organisms (MDROs): A bacteria of any kind that has become resistant to many different antibiotics.
Standard precautions 15.) Standard precautions: The application of a set of procedures specifically designed to minimize or eliminate the passage of infectious disease agents from one individual to another during the provision of healthcare services.
Clinical guidelines 16.) Clinical guidelines: The descriptions of medical interventions for specific diagnoses in which treatment regimens and the patients’ progress are evaluated on the basis of nationally accepted standards of care for each diagnosis.
Clinical Laboratory Improvement Amendments (CLIA) 17.) Clinical Laboratory Improvement Amendments (CLIA): The 1988 reenactment of the 1967 Clinical Laboratory Improvement Act, the federal regulations outlining the quality assurance activities required of laboratories that provide clinical services.
Clinical practice standards 18.) Clinical practice standards: The established criteria against which the decisions and actions of healthcare practitioners and other representatives of healthcare organizations are assessed in accordance with state and federal laws, regulations, and guidelines; the codes of ethics published by professional associations or societies; the criteria for accreditation published by accreditation agencies; or the usual and common practice of similar clinicians or organizations in a geographical region.
Core processes 19.) Core processes: The core processes involved in care, treatment, and services to patients are assessing patient needs; planning care, treatment, and services; providing the care, treatment, and services that the patient needs; and coordinating care, treatment, and services.
Critical pathways 20
Evidence-based medicine 21
Facility quality-indicator profile 22
Minimum Data Set (MDS) for Long-Term Care 23
Standards of care 24
Tracer methodology 25
Transfusion reaction 26
Case management 27
Community needs assessment 28
Continuum of care 29
Gantt chart 30
Indicator 31
Customers 32
Direct observation 33
Expectations 34
External customers 35
Internal customers 36
Interviews 37
Survey tools 38
FMEA Failure Mode and Effects Analysis (FMEA)
PCEs Potentially Compensable Events (PCEs)
HAI Healthcare-associated infection (HAI)
CLIA Clinical Laboratory Improvement Amendments (CLIA)
Name the FOUR (4) Core Processes Involved in care treatment, and services to Patient: 1. Assessing Patient Needs
2. Planning Care
3. Providing Care
4. Coordinating Care
What are National Patient Safety Goals? And who were they created by? The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them ... The Joint Commission.
What are National Patient Safety Goals? And who were they created by? The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them ... The Joint Commission.
What do the National Patient Safety Goals state about administering medication and/or blood transfusions? THAT TWO (2) PATIENT IDENTIFIERS ARE USED! ALSO, ONE OF THE GOALS ARE THAT CONTAINERS USED FOR BLOOD AND OTHER SPECIMENS ARE LABELED IN THE PRESENCE OF THE PATIENT!
Describe the 3 aspects necessary to carry out a blood product transfusion. 1. Before initiating a blood product transfusion, the patient is matched to the blood product, and the blood product is matched to the order using either a two-person verification process or an automated identification technology such as bar coding. 2. When using a two-person verification process, one individual conducting the identification verification must be the qualified transfusionist who will administer the blood product to the patient. 3. When using a two-person verification process, the second individual conducting the identification verification must be qualified to perform this task.
MDROs stands for...? MultiDrug-Resistant Organisms (MDROs)
MRSA Methicillin-Resistant Staphylococcus Aureus (MRSA)
CAI versus HAI CAI = Community Acquired Infection ...... HAI = Healthcare Acquired Infection
CDC Centers for Disease Control and Prevention (CDC)
APIC Association for Professionals in Infection Control and Epidemiology (APIC)
APHA American Public Health Association (APHA)
CDC, APIC, & APHA all pertain to which aspect of health service? CDC, APIC, & APHA all pertain to Infection
Nosocomial Infections could also be referred to as ....? Hospital Acquired Infections (HAI)
Unexpected deaths or unanticipated major loss of function from nosocomial infections are ____________? Sentinel Events
Why does infection spread so quickly in the health care setting? ?
T/F All states have required (infection) reporting lists? True
When a _____1_____ happens regarding a death due to infection a _________2_________ must be done and reported to the ________3________? When a sentinel event happens regarding a death due to infection a root cause analysis must be done and reported to the Joint Commission.
Staphylococcus Staphylococcus
Hepatitis A, B, C, D, E Hepatitis A, B, C, D, E
Tuberculosis Tuberculosis
What are the Universal Precautions that should be observed in a health care facility to control infection? Every patient in the healthcare setting should be treated as if they may have an active bloodborne pathogen disease.
What does NNIS stand for? The National Nosocomial Infections Surveillance System (NNIS)
What does the NNIS do? Data collection organization that provides comparative data regarding rates for healthcare-associated infections (HAI)
Explain Universal Precaution. Universal Precaution is an enancompassing rule health professionals practice by which they treat every Pt as though they were infected with a bloodborne pathogen. (any bodily fluid semen, feces, urine, vomit, blood, any fluid)
Name the 5 QI Toolbox Techniques discussed in this unit. 1. Surveys
2. Interview Design
3. Gantt Chart
4. Flowcharts
5. Cause-and-Effect or Fishbone DIagram
Which QI Toolbox Technique does this statement best describe: "An analytical tool used to illustrate the sequence of activities in a complex process."
Which QI Toolbox Technique does this statement best describe: "An investigational technique that facilitates the identification of the various factors (i.e., Manpower, Material, Methods, and Machinery) that contribute to a problem."
Cause-and-Effect, or Fishbone Diagram
Which QI Toolbox Technique does this statement best describe: "A discussion of the qualifications and experiences of a job applicant with respect to the employment process; or a discussion about an organization with its leadership during the accreditation or licensure survey process." Interview
Which QI Toolbox Technique does this statement best describe: "A type of data display tool used to schedule a process and track its progress over time." Gantt Chart
Which QI Toolbox Technique does this statement best describe: "Research instruments that are used to gather data and information from respondents in a uniform manner through the administration of a predefined and structured set of questions and possible responses." Survey TOOLS
MSDRG Medicare Severity Diagnosis Related Groups (Medicare Reimbursement) ... (MSDRG)
POA Present on Admission (POA)
What are 'Orphan Drugs' ? Rx, or medicines, which have been developed to treat RARE conditions. (Orphan Drugs = Tx Rare Dx)
HMO Health Maintenance Organization (HMO)
PPO Preferred Provider Organization (PPO)

Continuum of Care
Name the 4 'Trends' in Healthcare for Americans. 1. Americans demand A+++ medical technology.
2. 3rd Party Payers ... 1st Party Payers = Pt ... 2nd Party Payers = MD .. 3rd Party Payers = Insurance Companies
3. Employers providing health insurance ... #1. __?__ #2 Government #3 Private Health Insurance ex: Anthem Blue Cross Blue Shield
4. Liability Insurance Premiums = Malpractice Insurance
Explain the structure and meaning behind the Continuum of Care model. It is structured as a hierachical progression through the medical world. Beginning on the far left with the absolute most simple and basic form of health service a Pt could recieve which is a Doctor's Office Visit... As you move further along to the right of the Continuum of Care model you progress into more severe, specialized, and costly types of health service. The model ends on the far right with 'Hospice' Tx. Which is a palliative type of treatment used at the end of life.
RAC Recovery Audit Contractor (RAC)
What is the duty of a RAC? a RAC, or Recovery Audit Contractor, identifies and recovers improper Medicare payments paid to healthcare providers under fee-for-service (FFS) Medicare plans.
FFS Fee-For-Service (Medicare Service which is Audited by RAC's)
DRG Diagnosis-Related Group (DRG)
A Recovery Audit Contractor may cover (audit) Medicare affiliated HCO's in Kentucky, or what they might call ' ___?___ B' Region B
PPS Prospective Payment System (PPS)
A PPS is based on what ... ? Also what is it used for ... ? A prospective payment system (PPS) is a means of determining insurance payments based on predetermined prices, commonly from Medicare. Payments are typically based on codes provided on the insurance claim. Examples of these codes include:
  • Diagnosis-related groups (DRG) – for hospital inpatient claims
  • Ambulatory Payment Classification – for hospital outpatient claims
  • Current Procedural Terminology – for other outpatient claims
What is 'Case Management'...? & What does a 'Case Managers' ob entail...? Case Management is a process that insures that Pt's are getting everything they need from the HCO. A case manager could have a HSA background, and they would be a middle-man between Pt complaints & the HCO... stop a lawsui from happening. Nip it in the bud.
Define: Risk Risk is an exposure to the chance of injury or financial loss.
IOM Institute of Medicine (IOM)
These 3 statements are all examples of ____?
"Surgeons knife nicks something it shouldn’t" "Patients do not always respond to therapy" "44,000-98,000 die in hospitals each year from medical errors (IOM)"
(Risk) ... Unintended Consequences of T
PCEs Potentially Compensable Events (PCE's) -
What is a PCE? Give an example. A PCE, or Potentially Compensable Event, is an occurence involving injury or property loss. PCEs generally end with the HCO paying out a sum of money to compensate the victim (after trail or prior). Example: Wrong side amputation.
What does this statement describe? "Any events resulting in unanticipated patient death or major permanent loss of function and 2) events involving one of the following items: •Suicide in a care setting staffed around the clock or within 72 hours of discharge •Abduction of a patient of any age •Infant discharge to a wrong family •Rape •Hemolytic transfusion reaction •Surgery on a wrong patient or wrong body part •Unintended retention of a foreign object after surgery" The Joint Commission's Criteria of a Sentinel Event.
Who are 'Risk Managers"? What do they do? The background of a Risk Manager could range from a HSA Student to a Lawyer. Risk Managers seek to discover present risk HCOs could potentially encounter. Avoidance!
Occurrence report, aka (_____?_____) ... Define. Occurence Report = Incident Report ... A standardized form that is filled out in a very detailed manner. The form highlights a significant (negative) event that occured within the facility in a very clear concise manner. ... . §Data should be coded for easy entry into a database management system for incident tracking
NPSG(s) NPSG(s) = National Patient Safety Goals
What are NPSG? Who maintains NPSG? Who uses NPSG? NPSG = National Patient Safety Goals. They are maintained and updated annually by The Joint Commission. They are used by all Joint Commission accredited healthcare facilities. Each (type?) of facility has their own set up NPSGs.
Give two examples of NPSGs. NPSG Example #1: Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

NPSG Example #2: Improve staff communication NPSG.02.03.01 Get important test results to the right staff person on time.

NPSG Example #3: Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

Measuring the Effectiveness of Managed Care Organizations: Define:NCQA National Committee for Quality Assurance (NCQA)
Measuring the Effectiveness of Managed Care Organizations: Define:HEDIS Health plan Employer Data Information Set (HEDIS)
What does the NCQA do? The National Committee for Quality Insurance accredits HEALTH INSURANCE COMPANIES ... NCQA = Accredit Health Insurance Co.
The NCQA develops ___?___. Health plan Employer Data Information Set (HEDIS), is developed by the NCQA, or National Committee for Quality Assurance.
What is the structure & purpose of HEDIS? HEDIS, or Health plan Employer Data Information Set, grades health insurance companies like a report card ... Sends this summary out to employers to aid in their decision.
___?___ , or given incentives to provide good performance. Pay for Performance, or P4P, or Value-Based Purchasing.
Explain P4P, aka Value-Based Purchasing. Pay for Performance (P4P / Value-Based Purchasing) is a payment model that rewards physicians, hospitals, and other health care providers for meeting certain predetermined performance measures for quality and efficiency ... cont. ... Providers under this arrangement are rewarded for meeting pre-established targets for delivery of healthcare services. This is a fundamental change from fee for service payment.
MDS Minimum Data Set (MDS)

Explain - Root-cause analysis
§Process used to identify the basic or causal factors the underlie variation in performance •Currently, sentinel events are voluntarily reported to JC –All healthcare organizations can benefit from “lessons learned” §Some state licensing agencies require mandatory reporting

Explain Cause-and-effect or Fishbone Diagram
The “fishbones” indicate the causes of a situation from all perspectives ... The “fish head” indicates the effect
Asking 'Why?' repeatedly is a characteristic of what analyitical technique? Root-Cause Analysis In any situation, several levels of proximate causes must be identified and worked through to finally uncover the root causes. Asking Why? repeatedly helps investigators to arrive at root causes.
The Joint Commission requires that a ____________?__________ be done within 45-days of a sentinel event. Root-Cause Analysis
When an incident occurs what should be placed within the Pt's Medical Record... ? Be specific. Medical Record Always document incidents in a patients medical record Page 207 •Details should be limited to those documenting care given to the patient •No details about how or what contributed to the incident •No reference made to an incident or occurrence report being completed.
Medical Record inclusion/exclusion continued ... the patient’s medical record, the details should be limited to those documenting care given to the patient. No details about how or what contributed to the occurrence should be recorded. No mention should be made in the patient’s medical record of an incident or occurrence report having been completed.
Name the '8' types of Sentinel Events.
1. Fall
2. Restraint
3. Wrong Side Surgery
4. Medication Error
5. Suicide
6. Delayed Tx
7. Surgery
8. Other

What are 'Near Misses" ... ?
An event or situation that did not produce patient injury, but only because of chance. This good fortune might reflect robustness of the patient (e.g., a patient with penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart).
Near Misses (book definition) An organization also should include near misses in its definition of events that require intense investigation. Near misses include occurrences that do not necessarily affect an outcome but, if they were to recur, would carry significant chance of being a serious adverse event. Near misses fall under the definition of a sentinel event but are not reviewable by the Joint Commission under its current sentinel event policy. Near misses are a valuable tool for evaluation of processes and procedures, especially in high-risk areas or areas of high volume in facilities. ... An opportunity to improve patient safety-related practices based on a condition or incident with potential for more serious consequences.
What is the "Sentinel Event Alert" ...? Book Definition of "Sentinel Event Alert" - These processes are researched by experts, and a regular Joint Commission notification titled “Sentinel Event Alert” defines these processes and identifies measures that can be used to prevent errors and improve outcomes ... Wikipedia & My Words- The "Sentinel Event Alert" is a publication dispersed by The Joint Commission "sentinel event alerts" identifying specific sentinel events, their underlying causes, and steps to prevent recurrence.
The National Committee for Quality Assurance (NCQA) developed The Health Plan Employer Data Information Set....... to.......... ? is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks.
Procedures to address the flow of information from one practitioner to another were also put in place, or _____? Discharge Planning.
Name the FIVE (5) Steps involved in Discharge Planning. 1. Perform Preadmission Care Planning
2. Perform Care Planning at the Time of Admission
3. Review the Progress of Care
4. Conduct Discharge Planning
5. Conduct Post-Discharge Planning
OSHA Occupational Safety and Health Administration (OSHA)
LIP Liscensed Independent Practitioners (LIPs)
Tuberculin TB
HIPAA Health Insurance Portability and Accountability Act (
Explain The Joint Commission's Tracer Methodology. JC Tracer methodology: A process Joint Commission surveyors use during the on-site survey to analyze an organization’s systems, with particular attention to identified priority focus areas, by following individual patients through the organization’s healthcare process in the sequence experienced by the patients (Joint Commission 2008c).
Explain JC Tracer Methodology: [JC Website Definition] The Joint Commission’s on-site survey process includes tracer methodology. Tracer methodology is an evaluation method in which surveyors select a patient, resident or client and use that individual’s record as a roadmap to move through an organization to assess and evaluate the organization’s compliance with selected standards and the organization’s systems of providing care and services. Surveyors retrace the specific care processes that an individual experienced by observing and talking to staff in areas that the individual received care. As surveyors follow the course of a patient’s, resident’s or client’s treatment, they assess the health care organization’s compliance with Joint Commission standards. They conduct this compliance assessment as they review the organization’s systems for delivering safe, quality health care.
Explain Core Measures: Core measures: Sets of patient care characteristics that the Joint Commission and CMS have determined to reflect the quality of care an organization can provide for important diagnoses.
Explain Clinical Guidelines Clinical guidelines: The descriptions of medical interventions for specific diagnoses in which treatment regimens and the patients’ progress are evaluated on the basis of nationally accepted standards of care for each diagnosis.
Clinical Guidelines are ... ? Internet Definition Clinical Guidelines are .... recommended evidence-based procedures for management of certain diagnostic and/or therapeutic situations, such as a particular disorder (e.g., Type II diabetes). Typically released as text documents by professional medical associations or governmental bodies
This QI Toolbox Technique type of chart could be used to estimate the LOS on pneumonia. Gantt Chart
What am I? Gantt Chart
Principle Dx ... & ... Provisional Dx [Which is b4 study? After?] Principle Dx = After
Provisional Dx = Before
ORYX Initiative (Joint Commission) The ORYX (1995) Initiative was the creation of "Core Measures"
ORYX Initiative (Joint Commission) The ORYX (1995) Initiative was the creation of "Core Measures"
PSO Patient Safety Organization (PSO)
Lore surrounding the "ORYX Initiative" In 1997, JCAHO began including outcomes and other performance data into the accreditation process (the "ORYX initiative"). Information gained allowed the Joint Commission to develop National Patient Safety Goals to promote specific improvements in patient safety.[55] The Goals highlight problem areas in health care and describe evidence-based solutions. Examples include prevention of falls, patient identification, reducing hospital infections and pressure ulcers, and improving hospital staff communication. In addition, the Joint Commission created a "do not use" list of abbreviations[56] in 2004 to avoid acronyms and symbols that lead to misinterpretation.
STP Special Treatment Procedures (STP)
Restraining Mental vs Non-Mental Pt's Restraint and seclusion standards are highly defined by the Joint Commission, CMS, and state licensing agencies. There is clear distinction in the regulations about the use of restraint and seclusion for nonbehavioral health patients versus behavioral health patients. There are multiple performance improvement monitors required for any use of restraint or seclusion in all facilities. Restraint or seclusion is limited to emergencies in which there is an imminent risk of a patient inflicting physical harm to himself or herself, staff, or others and in which nonphysical interventions would not be effective. Most of the monitors are directed toward patient safety, timeliness, care, dignity, and least restrictive use. In the ER patient’s case, he is a nonbehavioral patient, and the use is for medical purposes to prevent him from accidentally removing his tube during sedation. This intervention would include temporary immobilization for a medical procedure (gastric lavage) and would, therefore, be required to meet all the nonbehavioral restraint and seclusion standards.
[Long] Restraints Because a restraining device may be part of the patient’s written plan of care, all facility, state, and federal guidelines must be complied with and defined in the plan of care. Protective restraint devices include wrist restraints, jacket restraints, chairs with restraining tables, restraints to stabilize a patient’s body during surgery, and side rails on hospital beds. Such protective restraint devices prevent something from happening. One example is the use of head stabilization devices for dental procedures. The use of restraints involves an increased risk of client deaths with pursuant legal risks and, therefore, requirements for monitoring during their use. On admission, an initial assessment of the patient’s needs for restraints use should occur, including a discussion with the patient and his or her family about a least-restrictive progression of interventions prior to the possible use of restraint; this assessment and discussion should be documented. Independent licensed practitioners should be credentialed for the privilege of assessing and applying restraint and seclusion. Continued training and documentation of staff competency for seclusion/restraint procedures and protective devices must be documented. It is also very important to document leadership philosophy, education, and commitment to the facility-wide elimination of the use of seclusion/restraint procedures. The primary focus of training for facilities includes staff competency in a number of de-escalation techniques and safety procedures as well as facility philosophy about restraint and seclusion. The Joint Commission (1999) wanted to reduce the frequency of seclusion/restraint across all facilities through use of the PI process to identify opportunities to reduce the risks associated with these procedures. The Joint Commission (2003) was particularly concerned about the use of restraint and seclusion and protective devices in long-term care and rehabilitation settings because the procedures may infringe on patients’ rights and have been identified through the sentinel event alert process as high risk. There are written policies outlining the use of restraint for nonbehavioral purposes such as for an emergency room patient. These policies are approved by the medical staff and nursing leadership of the facility. Common items included in these policies are: • Protection of the patient’s rights, dignity, and well-being • Use of restraint based on the patient’s assessed needs • Use of the least restrictive method of restraint • Safe application and removal of restraints • Monitoring and reassessment of patients who are restrained • Methods for meeting the physical needs of patients who are limited by restraint • Risks posed by restraints to vulnerable patient populations such as ER and pediatric patients or patients who are cognitively or physically challenged • Discussion of the use of restraint with the patient and family • Limitation of written orders for restraint to licensed independent practitioners • Renewal of orders in accordance with law and regulation • Frequency and content of entries in the patient’s health record for each episode of restraint Use of restraint for nonbehavioral purposes is usually initiated by an individual order from a licensed independent practitioner (LIP) or by written approved protocol. A registered nurse (RN) may initiate the order based on an assessment of the patient, but the LIP must be notified immediately and must provide a verbal or written order within 12 hours of initiation of the use of restraint. Within 24 hours of the initiation of the order for use of nonbehavioral restraint, the LIP must examine the patient. Each 24 hours of continued use of nonbehavioral restraint requires an order from the LIP based on his or her examination of the patient. Written protocols for the use of restraint for nonbehavioral health purposes include the following items: guidelines for assessing the patient, criteria for the use of restraint, criteria for monitoring the patient and reassessing the need for restraint, and criteria for when the restraint can be discontinued. Only authorized staff who have been educated to restraint standards and hospital protocols can maintain and discontinue restraint for nonbehavioral purposes. Any patient in restraint for nonbehavioral health purposes must be monitored at a minimum of every 2 hours and more frequently based on the individual assessment of the patient’s needs. All facilities are required to collect and analyze data on the use of nonbehavioral restraint, and these data are analyzed statistically and reported based on the facility’s policies. Opportunities for improvement of care in this area are based on statistical analysis of the data. Facilities are required to take action when planned improvements in the use of nonbehavioral restraints are not achieved or not sustained. Restraint and seclusion for behavioral health purposes has some different guidelines and policies for care. The hospital’s approach to the use of restraint and seclusion for behavioral health purposes includes the following: • Its commitment to prevent, reduce, and work to eliminate the use of restraint and seclusion • The need to prevent emergencies that have the potential to lead to the use of restraint and seclusion • The use of nonphysical interventions as the preferred interventions • Limitation of the use of restraint and seclusion to emergencies involving imminent risk of a patient causing self-harm or harm to others, including staff • The responsibility to discontinue restraint or seclusion as soon as possible • The need to raise awareness among the staff about what restraint or seclusion may feel like to the patient • Preservation of the patient’s safety and dignity when restraint or seclusion is used Written policies and procedures guide the use of restraint and seclusion for behavioral purposes. These policies address staffing levels and staff competence. Each patient must be assessed during the initial examination for any concerns related to physical or sexual abuse, or any physical disabilities or limitations that may cause harm or place the patient at increased risk. Techniques that would help the patient to control his or her behavior should be noted in the assessment. Family members may be educated about the facility’s approach to restraint and seclusion and asked to help in minimizing the need for restraint and seclusion unless their participation is contraindicated by the patient’s condition. Staffing levels for restraint and seclusion are based on staff qualifications, the physical design of the environment, patient diagnoses, patient co-occurring conditions, patient acuity level, and age and developmental functioning. Other items addressed in these policies are as follows: • The patient’s initial assessment • The role of nonphysical techniques in behavior management • Limiting restraint or seclusion to emergencies • Notifying the patient’s family when restraint or seclusion is initiated
Patient Advocacy Patient Advocacy- To support the patient through difficult interactions with the healthcare organization -“Damage Control” -All licensed healthcare organizations are required to inform patients of their rights
When a PCE occurs the Risk Manager ... ? ...? vThe Risk Manager: §Continues to represent the facility and coordinates all requests for information by subpoena duces tecum §Explains the organizations perspective §Remains open to negotiations of settlement §Reports information to the organizations insurer