Clinical Risk Management Strategy - Program Overview

Small Rural Hospital Clinical Risk Management Program

Formal quality improvement or risk management programs have long been widely used in industry and service organisations. Early risk management programs were primarily focussed upon controlling litigation and protecting the organisation or individual from claims. Over recent years studies of adverse events in healthcare have brought a growing awareness of the scale of the problem of harm to patients.

Gradually the need to address underlying clinical and system problems became apparent and the concept of risk management in the healthcare sector has developed and broadened over recent years to include strategies aimed at reducing the incidence of harm and improving patient safety and the quality of care.

Clinical Risk Management and Small Rural Hospitals

Whilst it is feasible in larger institutions to have peer review with medical clinicians dedicated to a clinical risk program, small rural hospitals with only one or two doctors often find it difficult to sustain formal medical quality improvement programs.

One significant problem for doctors who work closely together, is difficulty in objectively reviewing the medical records of patients treated by their neighbouring professional colleagues. Similarly it would be difficult for a doctor working on their own in a small hospital to objectively review their own work.

Adverse Event Screening Program

Dr Alan Wolff at the Wimmera Health Care Group, Horsham, initially developed the Limited Adverse Occurrence Screening process in the early 1990s. Since commencing in 1994 in the hospitals associated with West Vic Division of General Practice, the program has aimed to improve the quality and safety of patient care by providing rural general practitioners in small hospitals with a peer review process that monitors adverse patient events. An adverse event is an untoward occurrence, which under optimal conditions, is not a natural consequence of the patient's disease or treatment.

This clinical risk management program is based on screening hospital medical records to identify adverse events and select cases for review. This is a quality improvement program that offers true peer review for rural general practitioners. The doctors reviewing medical records are working in a similar environment to the doctors whose work is being reviewed and are, therefore, sensitive to the issues faced by doctors working in isolation in a small hospital. It is non-punitive and has general practice acceptance. This limited form of screening for adverse patient events was found to be highly efficient and effective in detecting up to 50 % of adverse patient events.

Hospital Benefits

By participating in this program, small hospitals gain the benefit of:

• An independent review of some of their medical records.
• Identification of both medical and system issues.
• Access to the details of recommendations resulting from a review of adverse events that have occurred at their hospital and others of similar size. This will promote improved patient care in the hospitals.
• General practitioner involvement with hospital quality improvement programs.
• Contributions towards overall clinical risk management and quality plans and reports.
• An improvement in the standard of documentation in the medical record.

General Practitioner Benefits

By participating in this program, rural General Practitioners will gain the benefit of:

• A cultural change from an attitude of individual blame to a non-punitive approach that acknowledges systemic causes for adverse events.
• Knowledge and experience being shared in a non-threatening way and recommendations leading to quality improvement in small rural hospitals.
• The identification of trends which individual general practitioners and small rural hospitals would have been unable to recognise on their own. It has provided input into state policy matters, and also provided local quality improvement forums with recommendations and material for further discussion on patient care, educational and system issues.
• Eligibility for clinical audit points towards maintaining vocational registration through the Royal Australian College of General Practitioners.
• Improved documentation to assist in the continuity of patient care.

Regional Implementation

Implementation of the Limited Adverse Event Screening program in other regions can be greatly assisted by the experience gained and lessons learned during the piloting and continuing developmental work conducted by the West Vic. Division of General Practice.

The key lessons learned include:

• To improve patient safety it is vital to:
  • Gain senior executive and clinician support
  • Change the culture of error management from one of apportioning individual blame for adverse events to one of identifying the systemic issues involved.
• Sound data collection, recording and management tools are required.
• Interested and motivated general practitioners are recruited to become reviewers.
• Administrative support is required to assist HIMs in small hospitals.
• A project worker is required to coordinate the program.
• Effective systems must be used to manage the highly confidential information securely.

Process Overview

The steps involved in the Limited Adverse Event Screening program are outlined below. Due to the highly confidential nature of the medical record, a system has been developed that maintains security of the copied medical record by coding data entry and the postage of all photocopied medical records by registered mail. The project officer will maintain a database to collate data associated with this program and track records.

1. The Health Information Manager at each of the participating hospitals screens the medical record of discharged patients during the routine coding process.

The screening tool consists of six criteria:

• Patient death
• Unplanned return to theatre within 7 days
• Unplanned re-admission within 28 days of discharge
• Transfer to another health service
• Patient length of stay greater than 35 days
• Unexpected re-admission following discharge from another hospital
• Any record which has been recommended by a doctor or other health professional for review. (Specify reason)

 

The relevant medical records identified by the screening criteria are photocopied and sent to the Division project officer. Administrative support should be provided to attend to the photocopying and mailing requirements.

2. The project officer then forwards the photocopied medical records to a general practitioner reviewer from a separate geographical area. The doctors are grouped in different geographical areas to provide anonymous “arms-length” review. GPs with similar specialities are used for review. The purpose of the medical review is to identify preventable adverse patient events.

3. The reviewing general practitioner returns the medical record to the project officer. If the record is deemed as requiring further discussion or more information is required, it is forwarded to the original treating GP for comment. The treating GP then returns the record to the project officer.

4. The reference panel comprises reviewing GPs and meetings are held quarterly to discuss the adverse events and identify any clinical and/or system issues that require recommendations. The reference panel chairman and the project officer collate the recommendations and a report is then sent to all general practitioners within the Division and the chief executive officers of the participating hospitals.

5. For the clinical risk management cycle to be completed, the reference panel recommendations are discussed at the various hospital quality improvement forums where recommendations may be modified and implemented at that level. A representative from each hospital provides feedback to the reference panel on courses of action or interventions undertaken by their hospital in response to each case and the recommendations offered.

Conclusion

The Limited Adverse Event Screening program provides a framework to assist small rural hospitals and clinicians to put in place interventions with the ultimate aim of improving patient care. In doing so the program will also contribute greatly towards a hospital’s overall clinical risk management and quality improvement strategies. Research conducted over a three year period by Alan Wolff and the West Vic. Division of General Practice showed a reduction of almost 50% in the number of adverse events.

This is an evolving program seeking input to promote continuing improvement. It is expected that there will be increased involvement as more hospitals participate in the program to comply with the State Government Patient Safety Strategy and funding requirements.  For further information or to comment on this program please contact Angela Boal on 03 5456 4086 or email Trish Natoli.