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toolkit

Onboarding Medical Assistants and Office Staff Toolkit

Patient advisories - medical assistants

Patient identification

Throughout the healthcare industry, the failure to correctly identify patients continues to result in medical errors. Accurate identification reduces the risks and consequences of patient misidentification, consequently improving patient safety. Patient misidentification has been shown as a root cause of many errors. The Joint Commission has listed improving patient identification accuracy as the first of its National Patient Safety Goals for 2014. The goal of using two patient identifiers is to reliably identify the individual as the person for whom the service or treatment is intended and to match the service or treatment to that individual.1 It makes sense that using two patient identifiers increases the potential for identifying the correct patient and decreases the potential for patient misidentification. A standardized process is the foundation of all safe patient identification practices.

What do you mean by two patient identifiers?

The two identifiers may be in the same location, such as a wristband. It is the person-specific information that is the “identifier,” not the medium on which that information resides. Acceptable identifiers include the individual's name, an assigned identification number, telephone number, or other person-specific identifier. Electronic identification technology coding, such as bar coding or RFID, that includes two or more person-specific identifiers (not room number) will comply with this requirement. Please remember that active patient involvement is also required in EP 1.2

The patient identification process should begin when the patient presents for medical care. The process should include obtaining a positive identification of the patient such as picture identification. The full name, date of birth and home address are elements that should be considered in the identification process. Based on the type of treatment to be provided, additional elements such as blood typing information should be implemented as part of the identification process. Most patients have more than one encounter with a provider, and the same process should be utilized on second and subsequent encounters.

Appropriate identification of patients impacts documentation. The medical record serves many purposes with the primary purpose to support and coordinate the medical care of a patient. Clinical communication is another way to describe the medical record. A good medical record is legible, timely, accurate, objective, complete and factual. Appropriate identification of a patient impacts documentation. Recording in the wrong patient’s chart is among the common documentation problems that can compromise care.3

Regardless of the technology or methods used for accurately identifying patients, careful planning for the processes of care will ensure proper identification prior to any medical intervention and provide safer care with significantly fewer errors.

Pre-procedure verification

Failure to conduct pre-procedure verification has been cited as a root cause of serious surgical adverse events. The Joint Commission (TJC) has emphasized this important process as one of its National Patient Safety Goals.

TJC has published the Universal Protocol for preventing wrong site, wrong procedure, and wrong person surgery™ which we outline in this Advisory.

Verify the correct procedure, for the correct patient, at the correct site.

  • When possible, involve the patient in the verification process.
  • Identify the items that must be available for the procedure.
  • Use a standardized list to verify the availability of items for the procedure. (It is not necessary to document that the list was used for each patient.) At a minimum, these items include:
    • Relevant documentation:Examples: history and physical, signed consent form(s), pre-anesthesia assessment
    • Labeled diagnostic and radiology test results that are properly displayed:Examples: radiology images and scans, pathology reports, biopsy reports
    • Any required blood products, implants, devices, special equipment
  • Match and then double check each of the items that are to be available in the procedure area to the patient.

Mark the procedure site

The site does not need to be marked for bilateral structures.

Examples: tonsils, ovaries

For spinal procedures: Mark the general spinal region on the skin. Special intra-operative imaging techniques may be used to locate and mark the exact vertebral level.

Mark the site before the procedure is commenced.

If possible, involve the patient in the site marking process.

The site is marked by a licensed independent practitioner who is ultimately accountable for the procedure, and will be present when the procedure is performed.

Ultimately, the licensed independent practitioner is accountable for the procedure – even when delegating site marking.

  • The mark should be unambiguous and used consistently throughout the organization.
  • The mark is made at or near the procedure site.
  • The mark shall be sufficiently permanent to be visible after skin preparation and draping.
  • Adhesive markers are not the sole means of marking the site.
  • For patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site, use your organization’s written, alternative process to ensure that the correct site is operated on.

Perform a time-out

Conduct a time-out immediately before starting the invasive procedure or making the incision.

  • A designated member of the team starts the time-out.
  • The time-out is standardized.
  • The time-out involves all of the immediate members of the procedure team: the individual performing the procedure, anesthesia providers, circulating nurse, operating room technician, and others who are participating in the procedure from the beginning.
  • All relevant members of the procedure team actively communicate during the time-out.
  • During the time-out, the team members agree, at a minimum, on (1) correct patient identity; (2) correct site; and (3) procedure to be performed.
  • When the same patient has two or more procedures, another time-out needs to be performed before starting each procedure.
  • Document the completion of the time-out. The organization determines the amount and type of documentation.

Summary

Address missing information or discrepancies before starting the procedure. At a minimum, mark the site when there is more than one possible location for the procedure and when performing the procedure in a different location could harm the patient. The procedure is not started until all questions or concerns are resolved.

Ultimately, it is up to each organization to decide when this pre-procedure information is collected and by which team member. It is always best to involve the patient directly in the process.

Use of Chaperones

It is important that providers develop a process for the use of chaperones. The American Medical Association’s (AMA) Opinion on the Use of Chaperones states, “From the standpoint of ethics and prudence, the protocol of having chaperones available on a consistent basis is recommended.1

Please consider the following suggestions from the AMA when formulating a practice policy for the use of chaperones:

  • Communicate the chaperone protocol to patients by prominent notice or through conversation with the patient.
  • Honor all requests for a chaperone.
  • Provide facilities for undressing, sensitive use of draping, and clear explanations on the various components of the physical examination.
  • Provide chaperones on a consistent basis, particularly for intimate examinations and those that may be construed as such.
  • When a chaperone is offered, keep inquiries of a sensitive nature to a minimum. Provide a separate opportunity for a private conversation between the patient and the physician.
  • Provide an authorized health professional to serve as the chaperone whenever possible.2

The American Academy of Pediatrics (AAP) offers the following guidance on the use of chaperones for children and adolescents.

“In the medical office setting, the physical examination of an infant, toddler, or child should always be performed in the presence of a parent or guardian. If a parent or guardian is unavailable or the parent’s presence will interfere with the physical examination, such as in a possible case of abuse or parental mental health issues, a chaperone should be present during the physical examination.” 3

It is important for providers to recognize the patient who requires too much of the physician's attention or who makes the physician feel uncomfortable, even when sensitive examinations are not taking place. Do not permit sexual advances by a patient. Strongly consider termination of the patient/physician relationship if this occurs.

The key to avoiding allegations of sexual misconduct is to be able to recognize patient behaviors and patient-physician encounters that have the potential to be misconstrued as a violation of the professional boundary that exists between the physician and his/her patient. The possibility of an allegation of sexual misconduct still exists despite the absence of inappropriate behavior by the physician or their staff.

By implementing these recommendations, a physician can reduce exposure to such allegations, and maintain a professional relationship with his/her patients.

The following references provide information and guidance on the use of chaperones:

  • American Medical Association. Opinion 8.21 - Use of chaperones during physical exams. Chicago, IL: American Medical Association, 1998.
  • American Medical Association, Council on Ethical and Judical Affairs. "Use of Chaperones During Physical Exams." June 1998.
  • American Academy of Pediatrics. "Policy Statement - Use of Chaperones During the Physical Examination of a Pediatric Patient." American Academy of Pediatrics (American Academy of Pediatrics), September 2011: 991-993.

Consult your state medical board for any state-specific guidelines on the use of chaperones.

Assessment of fall risks in patients 65 or older

Fall prevention is an important patient safety initiative. According to the Centers for Disease Control and Prevention (CDC), “each year, millions of adults aged 65 and older fall. Falls can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death.”1

Underscoring the significance of fall prevention, measures are included in the Physician Quality Reporting System (PQRS). PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs). Beginning in 2015, the program also applies a negative payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services.

Measure #154 (NQF: 0101) Falls: Risk Assessment, is a measurement of the percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months. The risk assessment must be comprised of balance/gait and one or more of the following: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months. Measure #155, is the percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.3

According to the guidance from the PQRS, a falls risk assessment is a clinical evaluation that should include the following, but are not limited to:

  • A history of fall circumstances
  • Review of all medications and doses
  • Evaluation of gait and balance, mobility levels and lower extremity joint function
  • Examination of vision
  • Examination of neurological function, muscle strength, proprioception, reflexes, and tests of cortical, extrapyramidal, and cerebellar function
  • Cognitive evaluation
  • Screening for depression
  • Assessment of postural blood pressure
  • Assessment of heart rate and rhythm
  • Assessment of heart rate and rhythm, and blood pressure responses to carotid sinus stimulation, if appropriate
  • Assessment of home environment

The falls risk assessment should be followed by direct intervention on the identified risk.4

According to one study, although one out of three older adults (those aged 65 or older) falls each year, less than half talk to their healthcare providers about it.5 Providers are encouraged to perform proactive risk assessments on patients aged 65 years and older with a history of falls and develop an individualized fall prevention intervention care plan.

MagMutual Risk Management and Patient Safety Consultants invite our policyholders’ questions. If you wish to discuss issues related to this article, or have other questions please call us at 1-800-282-4882, and ask for Risk Management.

Helpful Resources The Agency for Healthcare Research and Quality (AHRQ) developed Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care, AHRQ Publication No. 13-0015-EF, January 2013.

The CDC created the STEADI (Stopping Elderly Accidents, Deaths, & Injuries) Toolkit for Health Care Providers. Among the tool kit materials are a Fall Risk Assessment Tool, a Provider Pocket Guide for Preventing Falls in Older Patients, Guidance on Integrating Fall Prevention into Your Practice, and a list of medications that are linked to falls. These materials can be downloaded from the CDC website at www.cdc.gov.

The Joint Commissions, Center for Transforming Healthcare launched its seventh project which aims to prevent falls that occur in health care facilities. The Preventing Falls with Injury Project can be accessed on their website at www.centerfortransforminghealthcare.org

Plan of care for patient aged 65 and older with a history of falls

According to the Centers for Disease Control and Prevention (CDC), “each year, millions of adults aged 65 and older fall. Patient falls can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death.”1

The CDC’s web-based injury statistics show that, among older adults, falls are the leading cause of both fatal and nonfatal injuries. In 2013, 2.5 million nonfatal falls among older adults were treated in emergency department and more than 734,000 of these patients were hospitalized. In 2011, about 22,900 older adults died from unintentional fall injuries. The death rates from falls among older men and women have risen sharply over the past decade.2 The Joint Commission reported 11,000 deaths in U.S. hospitals annually, related to unexpected falls.

Underscoring the significance of fall prevention, measures are included in the Physician Quality Reporting System (PQRS). PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs). Beginning in 2015, the program also applies a negative payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services. The measures pertaining to falls is a two-part measure. Measure #154 (NQF: 0101) Falls: Risk Assessment, is a measurement of the percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months. Measure #155, is the percentage of patients aged 65 years and older with a history of falls, and who had a plan of care for falls documented within a 12 month period of time.3

According to guidance from PQRS, the plan of care must include:

  • Consideration of appropriate assistance device ; and ( Medical record must include: documentation that an assistive device was provided or considered OR referral for evaluation for an appropriate assistance device); and
  • Balance, strength, and gait training (medical record must include: documentation that balance, strength, and gait training/instructions were provided OR referral to an exercise program, which includes at least one of the three components: balance, strength or gait.4

According to one study, although one out of three older adults (those aged 65 or older) falls each year, less than half talk to their healthcare providers about it.5 Providers are encouraged to perform proactive risk assessments on patients aged 65 years and older with a history of falls and develop an individualized fall prevention intervention care plan.

Helpful Resources

The Agency for Healthcare Research and Quality (AHRQ) developed Preventing Fall in Hospitals: A Toolkit for Improving Quality of Care, AHRQ Publication No. 13-0015-EF, January 2013.

The CDC created the STEADI (Stopping Elderly Accidents, Deaths, & Injuries) Toolkit for Health Care Providers. Among the tool kit materials are a Fall Fisk Assessment Tool, a Provider Pocket Guide for Preventing Falls in Older Patients, Guidance on Integrating Fall Prevention into Your Practice, and a list of medications that are linked to falls. These materials can be downloaded from the CDC website at www.cdc.gov.

The Joint Commissions, Center for Transforming Healthcare launched its seventh project which aims to prevent falls that occur in health care facilities. The Preventing Falls with Injury Project can be accessed on their website at www.centerfortransforminghealthcare.org.

Patient complaints

"A complaint is a gift." This popular business adage suggests that the message within the complaint may contain valuable feedback.1 For every patient that officially complains, there are ten who complain to their family and friends.2 Complaints are usually verbalized by assertive people that have become really angry and hope by complaining that they will make things better for themselves or for the next person. Complaints occur commonly from breakdowns in communication.

While communication is a common thread in complaints, complaints should be examined closely. There is no complaint that is too trivial to the complainer so each complaint should be reviewed, checked for validity and managed appropriately. Resolving a patient’s dissatisfaction may limit damage. Patient satisfaction is an important risk management and patient safety gauge.

The following recommendations should be considered in the management of patient complaints:

  • Develop and implement a well-defined process for addressing and responding to patient complaints.
  • Review state guidelines for requirements on the declaration of patient rights.
    • For example, the Georgia Medical Board aka the Composite State Board of Medical Examiners (Composite State Board) requires the declaration to include the current phone number and address of the Composite State Board. In addition, the Composite State Board requires the following statement to be prominently displayed in a physician’s waiting room: "The patient has the right to file a grievance with the Composite State Board of Medical Examiners concerning the physician, staff, office and treatment received. The patient should either call the board with such a complaint or send a written complaint to the board. The patient should be able to provide the physician or practice name, address and specific nature of the complaint."
  • Designate a staff member to handle complaints, mitigate and respond.
  • Educate staff and providers to report complaints to management.
  • Collect, track and trend complaints to identify opportunities for improvement.
  • Contact your malpractice carrier if you are notified by your Medical Board that a patient has filed a complaint.

Complaints that are managed appropriately may be opportunities to transform a “disgruntled” patient into an advocate or practice champion.

Disclaimer

The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.