Case study

Question 1

Objective: To practice identifying different types of errors described in Reason’s Swiss cheese model.

Instructions:

• Consider the following scenario: In Florida, Clara, an active 94-year-old great-grandmother who still worked as a hospital volunteer two days a week, was admitted to the hospital for a bowel obstruction. She and her family, along with nurses from the hospital, said that there were too few nurses to check on her during the night when her eldest son went home to sleep for a couple of hours. Clara called the nurses to help her use the bathroom but when no one came, she climbed over the bed railing. Still groggy from surgery 20 hours earlier, Clara fell to the floor and broke her left hip. She died two days later during surgery to repair the hip fracture. “It was just too much for her,” said her grandson. “For want of one nurse, she died” (Gibson and Singh 2003, 101).
• Review the following list of latent errors, active errors, and preconditions that could have contributed to the event described in this scenario.

 

–Absence of one nurse and one nurse aide because of illness that night

–Clara’s advanced age not taken into consideration by caregivers

–Unavailability of staff to fill in for the two people calling in sick

–Falls risk assessment not complete on patient’s chart

–Decision to upgrade computed tomography scanner over purchasing safer patient beds

–Lack of training for nurses about specialized needs of elderly patients, especially related to their responses to medications

–The departure of Clara’s son

–Consistent scheduling of the night shift with minimum staff needed on the unit

–Bioengineering’s skipping of last month’s preventive maintenance check on the call light system (because the department was six weeks behind on its work)

–Admission of three new patients to this unit from the emergency department between 7:00 pm and 10:00 pm

–Falls precautions not implemented for this patient

Write the errors and risk factors in column 2 beside the appropriate category. (500 Words).

 

Category/Type of Failure	Error
Latent errors at the level of senior decision makers
Latent failures at the level of frontline management
Circumstances or conditions present when the patient’s accident occurred
Active errors associated with this event

 

 

Question 2: –

Objective: –

To practice quality improvement tools by applying them to an improvement effort in an ambulatory care setting.

 

Instructions

1.Read the following case study.

2.After you have read the case study, follow the instructions continued at the end of the case.

 

Case Study

Background

You have just been brought in to manage a portfolio of several specialty clinics in a large multiphysician group practice in an academic medical center. The clinics reside in a multiclinic facility that houses primary care and specialty practices, as well as a satellite laboratory and radiology and pharmacy services. The practice provides the following centralized services for each of its clinics: registration, payer interface (e.g., authorization), and billing. The CEO of the practice has asked you to initially devote your attention to Clinic X to improve its efficiency and patient satisfaction.

 

Access Process

A primary care physician (or member of the office staff), patient, or family member calls the receptionist at Clinic X to request an appointment. If the receptionist is in the middle of helping a patient in person, the caller is asked to hold. The receptionist then asks the caller, “How may I help you?” If the caller is requesting an appointment within the next month, the appointment date and time are made and given verbally to the caller. If the caller asks additional questions, the receptionist provides answers. The caller is then given the toll-free preregistration phone number and asked to preregister before the date of the scheduled appointment. If the requested appointment is beyond a 30-day period, the caller’s name and address are put in a “future file” because physician availability is given only one month in advance. Every month, the receptionist reviews the future file and schedules an appointment for each person on the list, and a confirmation is automatically mailed to the caller.

When a patient preregisters, the financial office is automatically notified and performs the necessary insurance checks and authorizations for the appropriate insurance plan. If the patient does not preregister, when the patient arrives at the clinic on the day of the appointment and checks in with the specialty clinic receptionist, she is asked to first go to the central registration area to register. Any obvious problems with authorization are corrected before the patient returns to the specialty clinic waiting room.

 

Receptionist’s Point of View

The receptionist has determined that the best way not to inconvenience the caller is to keep her on the phone for the shortest period possible. The receptionist expresses frustration with the fact that there are too many tasks in the office to do at once.

 

Physician’s Point of View

The physician thinks too much of his time is spent on paperwork and chasing down authorizations. The physician senses that appointments are always running behind and that patients are frustrated, no matter how nice he is to them.

 

Patient’s Point of View

Patients are frustrated when asked to wait in a long line to register, which makes them late for their appointments, and when future appointments are scheduled without their input. As a result of this latter factor, and work or childcare conflicts, patients often do not show up for these scheduled appointments.

 

Office Nurse’s Point of View

The office nurse feels that he is playing catch up all day long and explaining delays. The office nurse also wishes there was more time for teaching.

 

Billing Office’s Point of View

The billing office thinks that physicians are giving some care that is not reimbursed because of inaccurate or incomplete insurance or demographic information, and observes that some care is denied authorization after the fact.

 

Patient Satisfaction Measures

All clinics in the multiphysician group contract with a customer satisfaction measurement firm that administers customer surveys. This survey is sent to a random sample of patients at each clinic to determine their satisfaction ratings for eight dimensions of outpatient and inpatient care for adults and children:

• Respect for patients’ values, preferences, and expressed needs
• Coordination and integration of care
• Information and education
• Physical comfort
• Emotional support and alleviation of fear and anxiety
• Involvement of family and friends
• Transition and continuity
• Access to care

 

Performance Data

The last quarter’s worth of performance data for Clinic X are found in the following table.

Overall satisfaction with visit rated as very good or excellent       82%

Staff courtesy and helpfulness rated as very good or excellent   90%

Waiting room time for patients is less than 15 minutes   64%

Examination room waiting time is less than 15 minutes   63%

Patient no-show rate     20%

Patient appointment cancellation rate   11%

Provider appointment cancellation rate 10%

Rate of initial insurance claim rejections because of inaccurate or incomplete patient record documentation       4%

Patient preregistration rate         16%

Average number of patient visits per day             16

Range of patient visits per day   10–23

 

Instructions (continued)

3.Before continuing, completely read all of the remaining instructions.

4.Decide which problem you want to focus on as your first priority for Clinic X. Describe the problem and why you chose this problem.

5.State the goal for the improvement effort.

6.Identify the fundamental knowledge required by the improvement project team to solve this problem. Identify the people (professional group or service area) that should be represented on the team and the fundamental knowledge they bring to the team.

7.Document the current process (as it is described in the case narrative) using a process flowchart.

8.Identify the customers of the process to be improved and their expectations.

9.Explore and prioritize root causes of the problem by doing the following:

1. Brainstorm root causes and document the causes on a fishbone diagram.
2. Describe how you would collect data about how frequently the root causes contribute to the problem.

10.Review the following process improvement techniques. Select and explain the ones that apply to improving your process. Be sure to take into account what you have learned in steps 6 through 8.

1. Eliminate waste (e.g., things that are not used, intermediaries, unnecessary duplication)
2. Improve workflow (e.g., minimize handoffs, move steps in the process closer together, find and remove bottlenecks, do tasks in parallel, adjust to high and low volumes)
3. Manage time (e.g., reduce setup time and waiting time)
4. Manage variation (create standard processes where appropriate)
5. Design systems to avoid mistakes (use reminders)

11.Incorporating what you learned in steps 6 through 9, describe the changed process using a process flowchart or workflow diagram.

12.Decide what you will measure to monitor process performance to be sure your changes were effective and briefly describe how you would collect the data.

13.You have completed the “Plan” phase of the Shewhart cycle. Describe briefly how you would complete the rest of the Plan, Do, Check, Act cycle.

14.Save your answers to each part of this exercise. This material will become the documentation of your improvement effort.