Benchmark Assignment – Performance Management Plan Proposal
Grand Canyon University: Safety, Quality, and Interdisciplinary Approaches to Healthcare
Benchmark Assignment – Performance Management Plan Proposal
When opening a new radiologic imaging facility, it is pertinent to set a high standard of quality and gain a reputable high standard of care for patients. It is a difficult situation when a facility immediately has an unfortunate safety issue. This can easily turn into litigation, income loss, and close the facility doors. A risk management program is a way to act proactively use the resources to minimize, monitor, and control the probability or impact of unfortunate events. Listed below, are several goals to implement a risk management plan at a new facility to limit errors, patient safety issues related to reaction or contraindications, and how to report such items. A risk manager should put a performance management program into place. Staff that is qualified to assist should be assigned to the program for assistance. Following the protocol below and having the proper tools, resources, and qualified staff to assist will be a step towards a high quality of care and improved safety standards for patients, making the business a success.
Organizational Goals: Risk Management
Risk management in healthcare is a process to decrease the probability of mistakes made during any visit, treatment, or study for a patient. Risk management is an opportunity to also act proactively in hopes to catch any errors before they occur with the protocols that are set into action.
1. Patient identification protocol implementation with two verifications of identity.
2. Time Out procedure for invasive procedures involving injections, biopsies, or sedation.
3. Incident reporting protocols of near miss and safety incidents to staff, patients, and visitors of the facility.
4. Contrast media reaction learning assessment for staff with yearly follow up and new staff onboarding training.
5. Diagnostic imaging contraindications to external medical device protocols.
Outline of Organizational Objectives
C. Saves the company litigation, financial loss, settlements, and property loss.
- Patient Identification is the first line of action that should be taken when the patient enters the building.
- Implement proper protocol and decrease identification issues.
- Each staff member that encounters the patient should ask for two verifications of identity (Barnosky, 2014).
- This could be a date of birth, a full name, an address, or a phone number.
- This will reduce the chances of calling the wrong patient back to the x-ray room and imaging the wrong person due to an identification issue.
- Implement addition of software for EHS photo of patient on portable exams (Tridandapani, Olsen, & Bhatti, 2015).
- Time Out procedure for any type of more invasive study.
- Injections, biopsies, and any study for sedation.
- A pause to confirm the following:i). Patient identity, procedure, side the procedure is being performed on.
- Patient and staff confirm information the procedure will progress on(Lamb, 2009).
- Incident reporting protocol (staff members, 2018).
- Near miss or safety issue documentation.
- Documentation within 24 hours of the incident.
- Contact Supervisor.
- Fill in incident report with Risk Manager.
Summary of Relevant Performance Measures
- Contrast media used for radiology procedures is the highest risk for allergic reactions.
- Most frequent with women (Cannavale, Santoni, Passariello, & Arbarello, 2013).
- Findings also suggest that contrast reaction information should be updated yearly.
- Long term care with EHS alert in system.
- Staff should know how to access and evaluate patient for adverse reactions and document for EHS system for future reference.
- Confirmation of external medical devices are not contraindicated for ionizing radiation exposure per the manufacturer (FDA, 2018).
- Documentation on the EHS system for follow up care in radiology should also be documented
- Long term care management with alert in EHS system.
- Examples are diabetic glucose monitoring and heart monitoring systems.
- Removal is required for the study by some manufacturers.
- Studies may need to be postponed until heart monitors are removed (FDA, 2018).
The goals outlined above represent an example to improve quality of care and reduce safety risks while caring for patients. Many of the goals tend to overlap as they evolve with risk management. Safety issues are always a concern when treating patients. Risk is a possibility when we care for patients. We need to use our resources to implement new forms of identification for portable studies and verification to reduce human error.
Using the EHS system to documents many of the listed goals such as the external medical devices and the reaction to contrast will be beneficial. This will allow for improved higher standards of follow up care for patients.
This is also a way to collect and track data entered in the EHS system for clinical information. This clinical information can then be used to form decisions regarding alerts and refine the rules to care for patients and improve quality of care further. Improved patient care, greater efficiency, improved operations, improved satisfaction, and increased patient health and wellness for patients due to your facility is a successful business (Mansour, R., Thorne, M. (2014). The community will benefit from this facility. Many of these protocols will also allow for accreditation for programs through the Joint Commission.
Measurement of the contrast reactions and the medical device protocols would be a clinical measurement with the EHS system collecting data. Identity verification errors would be measured through incident reporting and would be a standardization process for asking information from the patient. Data will also be used to place photos on portable images for data collection and collect information of any errors as well, so this will include some data collection. devices and the reaction to contrast will be beneficial. This will allow for improved higher standards of follow up care for patients.
Baselines for measures should be set at the zero to give the proper count for reporting purposes and clinical data.
I feel an appropriate time frame to initially start would be quarterly. Then any changes or protocol issues can be updated sine the facility is new and updates may need to be approved for the program. Submission for eligible providers with EHS system allows for clinical practice registries to meet reporting requirements. The goals listed fall into the process measurement category. The measure should address a gap or variation in care and have the potential for improvement. This can be measured against other hospitals within the community to see how the facility rates.
Definition of Success
Success in an organization is defined as inspiring leaders that engage the staff to achieve goals to better the quality of the facilities work. In this case it would be improved patient care, greater efficiency, improved operations, improved satisfaction, and increased patient health and wellness for patients due to your facility is a successful business (Mansour, R., Thorne, M. (2014). The community will benefit from this facility. Many of these protocols will also allow for accreditation for programs through the Joint Commission. Data collected will help to further public health initiatives for the future. Good business strategies always look to further future goals. With positive goals for a healthy community and a qualified staff success will continue.
Barnosky, V. (2014). Patient identification errors in computed tomography: A plan, do, study, act approach to safety.Radiologic Technology, 85(6), 679CT-81CT. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=103968205&site=eds-live&scope=site
Cannavale, A., Santoni, M., Passariello, R., & Arbarello, P. (2013). Risk management in radiology. Radiology Management, 35(5), 1-9; quiz 20. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=107922008&site=eds-live&scope=site
FDA. (2018). Interference between CT and electronic medical devices. Retrieved from https://www.fda.gov/radiation-emitting-products/electromagnetic-compatibility-emc/interference-between-ct-and-electronic-medical-devices
Lamb, T. (2009). MRI safety “Initiating a time out procedure”. Journal of Radiology Nursing, 28(2), 64. doi:10.1016/j.jradnu.2009.02.009
Mansour, R., Thorne, M. (2014). Performance management fundamentals. Health Management Directory, (9/2014) Retrieved from www.healthmgttech.com
staff members. (2018). Successful quality management system in a radiology department. Healthmanagement .Org, 25(1), 1. doi:10.1109/TDEI.2018.8316730
Tridandapani, S., Olsen, K., & Bhatti, P. (2015). Improvement in detection of wrong-patient errors when radiologists include patient photographs in their interpretation of portable chest radiographs. Journal of Digital Imaging, 28(6), 664-670. doi:10.1007/s10278-015-9808-2