Risk Identification with General Causes in a Medical Center – A Facilitation Template

risk_identification_med_center_roj_16sept28_18jan20

This template may facilitate comprehensive risk assessment of all departments and business units of a medical center.  The risk assessment consists of risk identification, risk analysis, and risk evaluation.   There will just be adjustment based on the types of department, their functions and services (context).

Illustrations and Explanations:

All departments will include risk of downtime of the building of the medical center in their risk identification or register.  The downtime of building may be caused by earthquake, typhoons (strong winds), floods, fire and bombing.  Since all the departments are usually housed within one particular structure, then the risk analysis and risk evaluation will probably be the same. Risk treatment may also be the same, such as complying with the safe hospital initiative of the Department of Health.

Note: Downtime of building may lead to non-maximal utilization of services and financial losses (a negative effect).

All departments with equipment will include risk of downtime of the equipment used to render medical care and provide support to business development such as IT and facility.  The downtime of equipment may be caused by natural calamities and man-made causes or factors (like fires, lack preventive maintenance, buying non-durable equipment, suppliers with no or poor after sale services, etc.)  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the type of equipment.

Note: Downtime of equipment may lead to non-maximal utilization of services and financial losses (a negative effect).

All departments will include downtime of workforce as potential risk.  This is usually caused by lack of workforce and labor strike.  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the type of workforce.

Note: Downtime of workforce may lead to non-maximal utilization of services and financial losses (a negative effect).

All departments will include risk of lawsuits in their risk identification or register.  Lawsuits may be classified into medicolegal or non-medicolegal.  Medicolegal suits are those associated with medical care of patients.  Non-medicolegal suits are those not associated with medical care of patients.  The risk analysis and risk evaluation and risk treatment are essentially the same in all clinical departments (departments involved in medical care of patients) but may vary in degree (likelihood and impact) depending on the harm incurred by the patients.  Likewise, the risk analysis and risk evaluation and risk treatment are essentially the same in all non-clinical departments (departments not involved in medical care of patients) but may vary in degree (likelihood and impact) depending on the non-medical related harm incurred by the patients,guests and staff.

Note: Lawsuits lead to financial losses due to ligation (a negative effect) unless the risk is transferred to an insurance.

All departments will include risk of theft and losses in their risk identification or register. Theft are due to criminal acts committed either by staff or outsiders.  Losses may be due to faulty safekeeping of material goods or products, wrong counting or spoilage.   The risk analysis and risk evaluation and risk treatment of theft are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the type of theft.  For losses, the risk analysis and risk evaluation and risk treatment  are also essentially the same in all departments but may vary in degree (likelihood and impact) depending on the type of losses.

Note: Theft and losses lead to financial losses (a negative effect).

All clinical departments (departments rendering medical care of patients) will include account receivables in their risk identification or register.  Account receivables may be due to faulty assessment of financial capability of patients and lack or no control mechanism for prevention (faulty financial management system).  The risk analysis and risk evaluation and risk treatment are essentially the same in all clinical departments but may vary in degree (likelihood and impact) depending on the cost of medical services being rendered.

Note: Account receivables lead to financial losses (a negative effect).

All departments whether revenue or cost units will include risk for faulty accounting system in their risk identification and register.  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the extent of errors in accounting.

Note: Faulty accounting system leads to financial losses (a negative effect).

All departments whether revenue or cost units will include inefficient management system in their risk identification and register.  Inefficiency is due to poor alignment and integration of staff within a department and with other departments.  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the extent of inefficiency.

Note: Inefficient management system leads to financial losses (a negative effect).

All departments whether revenue or cost units will include non-maximal utilization of services in their risk identification and register.   This is usually caused by weak business development strategies and bad or tarnished reputation (aside from the downtime of building, equipment and workforce).  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the types of services.

Note: Non-maximal utilization of services leads to financial losses (a negative effect).

All departments shall include continual maximal utilization of services in their risk identification and register (on the positive effect side).  They should include strength, weakness, opportunity and threat analysis in their strategic planning to come out with a robust business development strategy.  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the types of services.

Note: Continual maximal utilization of services leads to positive financial growth (a positive effect).


ROJ@18jan29

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Integrating Quality, Safety and Risk Management Systems

Integrating Quality Management System, Safety Management System, and Risk Management System

Quality Management System and Risk Management System shall be integrated = Quality and Risk Management System
 
Slide5
 
“Quality” will subsume “Safety” if not otherwise specified.  If specified, Quality Management System and Safety Management System shall be integrated = Quality and Safety Management System.
Slide6
“Risk” will subsume “Safety” if not otherwise specified.  If specified, Risk Management System and Safety Management System shall be integrated = Risk and Safety Management System or Safety and Risk Management System.

Slide7

Slide8

Risk Management Policy – statement of the overall intentions and direction of an organization related to risk management.

To always use risk-based thinking and processes in planing and deciding all activities in the hospital so as to minimize negative effects and to maximize positive effects on accomplishment of objectives.

This policy shall be realized through:

  • Understanding the potential risks on quality and safe health care services, products, facility,  environment and business development;
  • Complying with all statutory and regulatory requirements on risk management;
  • Designing a structured, comprehensive, integrated, effective and efficient risk management system;
  • Providing adequate resources and highly competent staff to support the implementation of the management system;
  • Regularly evaluating and reviewing the results of implementation of the management system;
  • Continually improving the management system with innovations.
Quality and Safety Policy– statement of the overall intentions and direction of an organization related to quality and safe management.

To continuously provide quality and safe health care services, products, facility and environment to all our stakeholders (communities, families, patients, workforce and partners).

This policy shall be realized through:

  • Understanding the expectations of our stakeholders on quality and safe health care services, products, facility and environment;
  • Complying with all statutory and regulatory requirements;
  • Designing effective and efficient quality and safe management systems
  • Providing adequate resources and highly competent staff to support the implementation of the management system;
  • Regularly evaluating and reviewing the results of implementation of the management system;
  • Continually improving the management system with innovations.

ROJ@18jan28

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An Introductory to ROJHMC – Hospital Design and Operations Manual

Introductory on ROJHMC
ROJHMC stands for Reynaldo O. Joson Hospital and Medical Center.
This is a fictitious 100-bed capacity private level 2 general hospital and medical center that I, Dr. Reynaldo O. Joson, will use in designing and developing a governance and operations manual that can be used as a guide or template by hospitals and medical centers in the Philippines.
At this writing (2018), there are a lot of private hospitals and medical centers being constructed in the Philippines.  Everybody knows it is not easy to design and develop a hospital or medical center.
At this writing (January 24, 2018), I will be 69 years old in one week’s time (January 31, 2018) and will be 70 years old in one year’s time (my first count-down in life), and at the start of the year (January 1, 2018), I made a resolution to start 4 new projects for the next 5 years (up to 75 years old – my second count-down in life).  These 4 projects are (as published in https://rojoson.wordpress.com/2017/12/31/2018-life-plan):

– 100-Bed Level 2, Private General Hospital Design and Operations Manual
– Medical Curriculum Enhancement
– Options for Medical Management – Diagnostic and Treatment Procedures
– Clinical Research

Thus, this ROJHMC 100-Bed Level 2 Private General Hospital Design and Operations Manual.

I intend this Manual to be another one of my legacies to the Filipino people and to hospital administrators.
Why “hospital and medical center” in the name?  Why not just “medical center”?
Strictly speaking, “hospital” and “medical center” are the same and can be used synonymously although “medical center” has the connotation of bigger and being sophisticated. The Philippine Department of Health has these definitions:

DOH Definitions of Hospitals and Medical Centers

Hospital – a place devoted primarily to the maintenance and operation of health facilities for the diagnosis, treatment and care of individuals suffering from illness, disease, injury, or deformity or in need of obstetrical or other surgical, medical and nursing care. It shall be construed as any institution, building, or place where there are installed beds, cribs, or bassinets for 24-hour use or longer for patients in the treatment of diseases.

Medical Center- a hospital staffed and equipped to care for many patients and for a large number of kinds of diseases and dysfunctions using modern technology.

I purposely included “hospital” in the name of ROJHMC because “hospital” is more commonly used in the Philippines than “medical center” and is readily understood by the laypeople. Second, when I write the manual, particularly the operations part, I foresee it will be easier and shorter to use and write the term “hospital” than “medical center” (of course, with the caveat that these two terms will be used interchangeably).  For example, hospital quality management system instead of medical center quality management system; hospital infection rate instead of medical center infection rate; hospital financial management system instead of medical center financial management system; etc.  If I use “ROJMC,” I feel obliged to use “medical center” all the time and have to refrain from using “hospital” even when it is easier to use “hospital.”
ROJHMC, therefore, is a fictitious 100-bed capacity private level 2 general hospital and medical center. Furthermore, the context is that it is located in a Philippine urban community with modern amenities (as of 2018).  At the moment, there will be no specification as to the population and distribution of socioeconomic strata of the catchment community.

ROJ@18jan25

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Patients Rights and Responsibilities on Hospital Bills

The PhilHealth Benchbook requires all hospitals to have a publicized Patients’ Rights and Responsibilities.

Each hospital can come out with its own version as long as the following are included (based on PhilHealth Benchbook):

1.2b Patients’ rights include rights to: (a) good health (b) to information its confidentiality (c) privacy e.g. visual and auditory (d) participate in care decisions (e) withdraw consent without prejudice to care (f) second opinion.

1.2c Patients’ responsibilities includes: (a) to provide the hospital with truthful and complete information (b) to heed hospital regulations (c) to be an active partner in regaining and maintaining health (d) to ensure that their healthcare is paid for.

Last year, 2017, when I was trying to help a private hospital in the north formulate its Patients’ Rights and Responsibilities, I suggested a balance in the responsibilities and rights on patients’ hospital bills, meaning there must be a counterpart on the patients’ rights.

In the Philippines, all the Patients’ Rights and Responsibilities that I have seen so far include a declared responsibility for the patients and relatives to settle their hospital bills.  There is no corresponding declared rights on hospital bills.  Not stated but just implied, the patients and relatives have the right to examine and receive an explanation of their hospital bills.  What I suggested last year is to put an open statement like this: patients’ right to be billed accurately.

January 13, 2018, I encountered a situation which convinced me all the more all hospitals should bill patients accurately.

This patient underwent a breast mass excision under local anesthesia and on outpatient basis. I told and assured her before the operation her hospital expenses could be covered by the PhilHealth benefits of P5,200.00 (no need for out-of-pocket payment).  Before I left the operating room, I asked the operating room clerk how much was the hospital bill of my patient.  She said P9,000 +.  I was taken aback by her answer.  I investigated.  The laboratory department gave a charge of P7,600 for the histopathology of the 3-cm breast mass.   Before the operation, I computed the histopathology charge to be only around P2,100 to P2,400 for small to medium-sized specimen (based on experience with this hospital).  Image (2)

I called up the laboratory department and inquired further.  I was told by the laboratory department clerk the specimen “looked big.”  Therefore, she gave a charge for a large specimen (P7,600).  “What?  The specimen was just about 3-cm.”  I said.  I then asked her what were the bases for classifying specimens into small, medium and large.  I was expecting she would give an answer in term of numerical values such as more than 4 cm would be considered large; less than 2 cm would be considered small; etc.  She could not give me such kind of an answer.  When I said I would cancel my request for histopathology because the charge was unreasonable, she right away told me to wait and would ask her colleague in the laboratory department. When she came back to me, she openly admitted she made a mistake and would just make a charge of P2,700 (medium-size specimen).  In answer to my query on how the size of the specimen was being classified, she said any specimen that could not fit into the 100-cc plastic container being used in the operating room would be considered large.  I was not contented with the answer but I left it at that for the moment since she had offered to adjust the charge (P2,700 for medium specimen).  The total bill came out to be P4,924.57, still within the benefits of PhilHealth.

If I did not question the hospital bill, the patient would have shelled out around P4,600.00.  Patients usually do not know the bases of the charges.  They usually pay as billed.  Some will question. Majority will not.

This is the very reason for my advocacy to include in the Patients’ Rights to be billed accurately.   

It is correct to declare that patients have the responsibility to settle their hospital bills but it should also be stated that the patients have the rights to be billed accurately.

Side recommendations for physicians:

Physicians should help in the checking of charges of their patients’ hospital bill.

Physicians should be patient-advocates.

 



I took pictures of the specimen plastic container being discussed above:

IMG_0003

IMG_0008


ROJ@18jan15

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Alignment, Integration and Coordination Needed in a Care of a Patient

In a patient confined in a hospital, there are usually a good number of staff (physicians, nurses, medical technologists, radiology technicians, pharmacists, house keepers, etc.) taking care of him, that is, providing health care services.

See picture below:

people_in_one_episode_care

http://docplayer.net/14478453-Patient-experience-is-not-patient-satisfaction.html

There must be alignment, integration and coordination of the health care services to be provided in order to achieve quality and safe patient care and excellent patient experience.

Who should orchestrate this alignment, integration and coordination?

The attending or head physician?

The nurses?

The attending or head physician assisted by the nurses and the hospital-wide alignment, integration and coordination management system in patient care?

I think the best answer is the last one.

This is a challenge to all hospital administrators – how to accomplish the third task and responsibility!


ROJ@17dec9

 

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Governance of a Hospital Clinical Department Framework

Governance of a Clinical Department_roj_17dec6

 


ROJ@17dec6

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Quality vs Safety – Quality and Safety Patient Care – ROJoson’s Notes

Quality vs Safety – Quality and Safety Patient Care – ROJoson’s Notes

Quality vs Safety – Quality and Safety in Patient Care

ROJoson – 15feb12

Circa 1995s, I spelled out the universal goals in the management of a patient which consist of resolution of the patient’s health problem or concern in such a way that the patient does not end up dead, with disability, or with complication and in such a manner that the patient is satisfied and there is no medico-legal suit.  I have been using these formulated goals in the management of my patients.  I have also been telling my medical and surgical students to have these goals in mind whenever they treat patients.  I have not called these goals as quality or safety goals, just simply goals in the management of a patient.  It is only now as I prepare for a lecture on patient safety management to be held on February 12, 2015 that I come to realize that these goals are quality and safety goals.  One can see the quality and safety components if I restate the goals as such: resolution of the patient’s health problem (quality) in such a way that the does not end up dead (safety), with disability (safety), with complication (safety) and in such a manner that the patient is satisfied (quality) and there is no medicolegal suit (quality).

In 1999, when I started my journey in hospital quality management system, my practice had been to have “safety” subsumed by the goal of quality service and patient care without spelling it out.  It was only in 2010 when I was made aware by the assessors from Accreditation Canada International surveying Manila Doctors Hospital of the importance to have the “safety” goal spelled out.

So, what is the difference between quality and safety? Should the quality and safety goals be independent of each other?

Quality vs Safety (Agency for Healthcare Research and Quality)

Below is an excerpt from an article that gives a backgrounder on the evolution of safety from quality and attempts to differentiate the two. (Emmanuel L: What exactly is patient safety?  Ahrq.gov 2008)

“Part of the challenge lies in distinguishing safety from quality, a line that remains important to some, while being dismissed by others as an exercise in semantics. In 1998, the IOM convened the National Roundtable on Health Care Quality, which adopted the following definition of quality that was widely accepted: “Quality of care is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” (Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998; 280: 1000-1005.)  

Health care quality problems were classified into three categories: underuse, overuse, and misuse, all of which the evidence shows are common. Misuse was further defined as the preventable complications of treatment. Although the IOM Roundtable was careful to distinguish misuse from error (the latter may or may not cause complications), the misuse category became a common reference point for conceptualizing patient safety as a component of quality.

In 2006, Leape and Berwick observed that, as attention to patient safety has deepened, the lines between the overuse, underuse, and misuse categories have blurred. “It seems logical,” they wrote, “that patients who fail to receive needed treatments, or who are subjected to the risks of unneeded care, are also placed at risk for injury every bit as objectionable as direct harm from a surgical mishap.” (Leape LL, Berwick DM. Five years after “To Err Is Human.” What have we learned? JAMA 2005; 293: 2384-2390.)   

The National Patient Safety Foundation identified the key property of safety as emerging from the proper interaction of components of the health care system, thereby leading the way to a defined focus for patient safety, namely systems. (Cooper JB, Gaba DM, Liang B, et al. The National Patient Safety Foundation agenda for research and development in patient safety. Med Gen Med 2000; 2: E38.)  

Its goal has been defined as: “[t]he avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the process of care.” (Vincent C. Patient safety. London: Elsevier; 2006.)

Quality vs Safety; Quality and Safety (Accreditation Canada International)

Quality is “the degree of excellence; the extent to which an organization meets clients needs and exceeds their expectations”. Key attributes of high quality healthcare systems, as defined by the Institute of Medicine (U.S.) include safety, timeliness, effectiveness, efficiency, equity and patient centeredness.

Patient safety is often considered a component of quality, thus, practices to improve patient safety improve the overall quality of care.

Quality vs Safety; Quality and Safety (Joint Commission International)

Quality and safety are inextricably linked. Quality in health care is the degree to which its processes and results meet or exceed the needs and desires of the people it serves.  Those needs and desires include safety.

The Institute of Medicine defines quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Patient safety emerges as a central aim of quality. Patient safety, as defined by the World Health Organization, is the prevention of errors and adverse effects to patients that are associated with health care.  Safety is what patients, families, staff and the public expect. While patient safety events may not be completely eliminated, harm to patients can be reduced, and the goal is always zero harm.

The ultimate goals are quality of care and patient safety.

ROJoson’s Summary Statements: There is a difference between quality and safe patient care.  Safety is within the quality dimension.  It is recommended for the safety goals to be extracted from the quality goals for emphasis reason.  However, the ultimate goals should still be an alignment and integration of quality and safety in patient care.

ROJ-TPOR@15feb12


A Repost.


ROJ@17nov30

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