Error-proof your discharge planning process now
JCAHO's new policy opens the door for more malpractice cases
At the end of a long and hectic day in the hospital, a young mother is discharged with a new baby - but the baby in her arms isn't hers.
Because of an error in paperwork, a seriously ill patient is sent home prematurely and dies the next day from cardiac arrest.
Such nightmare scenarios, which are examples of sentinel events, can not only jeopardize your hospital's accreditation, but can leave you open to potential civil and criminal penalties - even if the problem resulted from systemic errors in the discharge planning process. And these events happen often enough that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), based in Oakbrook Terrace, IL, has targeted a tough new policy at violators.
Meant to be an incentive for hospitals to self-report catastrophic errors to JCAHO, the sentinel event policy is raising concerns that such information-sharing could lead to an explosion in the number of new medical malpractice cases leveled against hospitals and their employees. It's feared that when organizations share sensitive information with the Joint Commission, they may lose the confidentiality prerogatives of the statutes that ordinarily protect against the disclosure of such information. (For information on recent revisions to the sentinel event policy, see p. 87.)
The solution is to error-proof the processes that can lead to sentinel events, including (but not limited to) the process of discharge planning, says Larry Poniatowski, RN, associate director of the department of standards at the Joint Commission. But Poniatowski cautions that simply making your discharge planning process more efficient may not be enough to keep you out of hot water. For instance, he says, discharging an infant to the wrong family is likely to result from what he calls a mechanical error, "because the person who is actually retrieving and giving the infant doesn't validate that that's the right infant."
Because so many errors in discharge occur as a result of problems in the process of care, and more specifically, problems with the paperwork documenting that care, case managers must become involved to limit the possibility of catastrophe, says Larry Strassner, RN, MS, manager of health care consulting at Arthur Andersen LLP in Baltimore and former director of clinical pathways at Johns Hopkins University Hospital in Baltimore.
"If case managers are really doing case management, they have a full scope and understanding of the patient," Strassner says. "On admission or before, they get a full assessment and begin to pull together a picture of the patient's clinical, psychosocial, and economic needs. And they use that information in monitoring the care and discharge of the patient. Because they're clinicians, they can help to prevent sentinel events that could go unnoticed if there wasn't an expert clinician following the case."
Strassner adds that case managers may have a better chance than physicians at heading off such problems because they have a "bigger global picture" of the patient, including patient family issues and education. "So while the physician may focus attention on the cure or moving the patient through the care process, it's really the RN, the clinical specialist, who pulls it all together and makes sure those aspects are met."
Poniatowski also stresses the importance of having someone with a clinical background assume responsibility for discharge planning. "If the discharge planner is involved in the data and looking at the care given to the patient, there may be an opportunity for that individual to pick up a potential problem and bring it to the attention of the treatment team," he says. "If there are confusing things in the chart, or they find some potential errors in the chart, they may want to have a responsibility to say, 's look at this and see what the problem is.'"
That kind of oversight is crucial, Poniatowski says, because sentinel events most often occur as a result of general disorganization in the process of care and a lack of coordination in discharge planning. Poniatowski says the Joint Commission has come across many such cases, despite the fact that the organization has long recommended beginning discharge planning as soon as the patient is admitted.
Shorter LOS makes discharge planning crucial
"That's typically the best time for the discharge planner to get involved," he says. "Because the discharge planner is really the individual that would coordinate things and make sure that [the process] wasn't a patchwork quilt. That's what we really see as a problem in discharge planning: Typically, the patient's going to be discharged tomorrow and people are asking, `What do we do with them?' With length of stays of two and three days, that really has to occur very rapidly."
For example, before quality managers at the Boston VA Medical Center instituted a case management model and overhauled its uncoordinated discharge planning process, patients were often admitted without a treatment plan, and outpatient and home care services were woefully underutilized. As a result, inefficiencies in the process of care resulted in lengths of stay spinning of control and raising the possibility of a sentinel event. "We were using such archaic methods in our facility, just going along doing things like we had always done," says Deborah F. Creech, RN, BAN, MSM, director of quality management.
Creech says that although Veterans Affairs headquarters had mandated a systemwide total quality management program five years ago, Boston VA didn't institutionalize TQM until two years ago. Before that, the medical center would admit patients and then decide what to do with them, she says, despite an awareness that this approach would not meet current quality standards.
"It wasn't until the VA started pushing for changes and making the closer comparison to the private sector that we realized how outdated we were," Creech says. By creating a CQI team on discharge planning and implementing an effective case management model, Boston VA has managed to turn things around and has recently been recognized for its centers of excellence.
Strassner believes that, as at Boston VA, the best way to improve discharge planning is to fit it into a case management model. That doesn't mean the case manager alone should be responsible for discharge planning, but "she [should be] accountable for that coordination of the entire discharge-planning process. That may mean she'll need to bring in a social worker as needed. And clearly, she'll need to coordinate that with the payers."
Strassner adds that it's usually up to the acute care case manager, along with the payer case manager, to make sure that a patient's post-discharge needs are met. These include such things as home health, durable medical equipment, home IV therapy, and home physical therapy.
In the case management models Strassner has developed, discharge planning begins on admission. "When they identify that there are going to be post-discharge needs, the expectation is that the case manager immediately contacts the payer case manager and beings to coordinate with that individual," he says.
Information technology can also help to improve coordination in the discharge planning process - if it's applied wisely. E-mail and fax machines, for instance, can speed communication with physicians as well as outpatient and payer case managers about the services a patient received in the hospital and what the patient's current status is. Another option is to implement a telenursing system that allows discharged patients to call a hospital-run nurse advice line. Whatever the nurse shares with the patient could then be sent by e-mail to the physician the next day.
"Some have gotten even more sophisticated in saying, if the physician has a relationship with the telenurse, then based on the patient's condition, the nurse could automatically schedule an appointment and put the patient right on the physician's schedule," Strassner says.
Transcription leaves you open to error
But while information technology can be a benefit to care coordination, it's not a panacea. Some types of automation can actually introduce errors into the system, Poniatowski says. The best example of this is the use of electronic medical records, which the Joint Commission does not currently endorse. "We don't condemn it, certainly, but we also don't say that this is something that you need to move towards," he says. "To be honest, error can creep in because you're typically taking handwritten notes and then transcribing them into type."
Strassner agrees that electronic medical records currently aren't sophisticated enough to help prevent errors. "The more hand-offs, the more transfer of information, the greater the risk for error," he says.
For more information, contact the following:
Larry Poniatowski, RN, associate director of the department of standards at the Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. Telephone: (630) 916-5600.
Larry Strassner, RN, MS, manager of health care consulting at Arthur Andersen LLP in Baltimore. Telephone: (410) 234-3894.
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