I.

Morbidity and Mortality Meetings

a. Definition are traditional, recurring conferences held by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers. are usually peer reviews of mistakes occurring during the care of patients. are non-punitive and focus on the goal of improved patient care. occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. b. Purpose To provide a safe venue for the medical team to identify areas of improvement, and promote professionalism, ethical integrity and transparency in assessing and improving patient care. Provide a forum to teach curriculum on quality improvement and medico legal issues to the medical team and students. To foster a climate of openness and discussion about medical errors. c. Preparation Identify clinicians who will form the core group for the department M&M meetings, taking into account: the benefits of a multidisciplinary approach involving the working group the potential to broaden the group for specific cases, where significant input to care occurred from other clinical areas.

Appoint a senior consultant to be the Chair and to have responsibility for meeting management. Appoint a registrar or fellow with responsibility for case coordination and minute taking, outlining expectations. Book a regular meeting time. It is a requirement that meetings are held monthly.

d. Case Analysis Morbidity and Mortality Review There is an organizational expectation that all in hospital deaths will be reviewed and a standardized format for review followed Issues should be identified and, where appropriate, recommendations for system change made. It is important that the person responsible for implementing the change is identified and a due date established. Progress with implementation of recommendations should be reviewed at subsequent meetings. II. Sentinel Events

a. Definition any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness help aid in root cause analysis and to assist in development of preventative measures b. The Sentinel Event policy has four goals: 1. To have a positive impact in improving an individuals care,

treatment, or services preventing sentinel events

and

2. To focus the attention on understanding the factors that contributed to the event (such as underlying causes, latent conditions and active failures in defense systems, or organizational culture), and on changing the laboratorys culture, systems, and processes to reduce the probability of such an event in the future 3. To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention 4. To maintain the confidence of the public and accredited agencies in the accreditation process. c. Determination the Need for Focused Review When something goes wrong, the appropriate clinical experts are in consultation Administration Physician leadership Nursing leadership Risk Management Quality Management It is determined that the event meets the definition for sentinel events The event is a near miss (good catch) - the event has resulted or could have resulted in patient harm Problems keep repeating d. Action Plan: Do the Actions meet the following:

Address the root cause and contributing factors Specific Easily understood and implemented Developed by process owners Measurable Identifies opportunities for improvement Assigns responsibility for actions Target dates are set for completion Looks at follow up for effectiveness by using a measurement plan

e. Measure of Effectiveness Confirmation that what we wanted to accomplish did in fact occur Measures effectiveness of action, not the completion of the action All improvement will require change, but not all change will result in improvement G. Langley, et al f. Measurement answers the question Quality improvement measurement is for learning, not judgment, not research All measures have limitations Measurement should be used to guide improvement and test changes Focus on the changes made in the action plans

g. How to Measure: Complex and untimely Chart abstraction Financial reports Data obtained from existing databases and systems Guide change, indicate progress, timely Tally sheets Checklists Questionnaires

 Feedback interviews Observation Daily reviews Spread the Success/knowledge Share with staff and Administration Need to go beyond share at staff meeting - action is not sustained Collaborate with other units and sites Report sent to Medical Department for review/comments III. Credentialing and Clinical Privileging a. Definition Credentialing the systematic process of reviewing the qualifications and the health status of applicants for appointment to ensure they possess the education, training, experience and skill to fulfill the requirements of the position process of assessing and confirming the qualifications of a health care practitioner is the process for validating licensure, clinical experience, educational preparation, and certification for specialty practice Clinical privileging the process by which a practitioner is granted permission by the facility to provide the psychiatric, medical, or other patient care services, within well-defined limits, based on an individuals clinical competence as determined by peer review, training, licensure, and registration Clinical privileges are granted for a period not to exceed 2 years the process that health care organizations employ to authorize practitioners to provide specific services to their patients Re-privileging

the review and submission of clinical privileges after initial appointment at biannual intervals to assure that practice limits have not changed and that when conditions change, clinical privileges reflect those changes. Reappointment the biannual process of reevaluating the professional credentials, clinical competence and health status of providers who hold clinical privileges within the facility. b. Processes of Credentialing and Clinical Privileging o Certain essential elements of the credentialing and privileging process are common throughout health care organizations. o The interval for the process is usually at hire and every two years thereafter. o Inquiry phase- where a credentialing application is given to the practitioner for completion o Verification phase- Once the application is received, the verification phase begins where the applicants information is verified using primary source data. o Once the applicant has turned in all the necessary information and it has been verified, the CVU reviews the information and determines whether to credential the practitioner for the organization. To those accepted, the CVU sends a letter acknowledging their acceptance. The practitioner is usually approved for two years IV. Variance Reporting and Analysis

a. Definition Variance - an event that occurs outside the usual "normal" events in the organizational processes Variance Report

incidence report purpose is to identify circumstances or issues that contributed to the occurrence of the problem - engage in strategies to prevent recurrence or correct the situation b. Occurrence Types: 1. Injury Abrasion Bite Bruise Burn Contusion Laceration Needle stick Sprain Strain 2. Personal Belongings Damage/Loss Money Clothes Wallet 3. Miscellaneous AMA/discharge Refusing discharge Refusal of treatment 4. High Risk Event Alleged sexual activity AWOL CODE BLUE Elopement Elopement attempt Medical emergency Seizure activity Sexual aggression Suicide attempt 5. Falls With injury Without injury *witnessed/ unwitnessed c. Reporting Sentinel: a. Staff - immediately contacts the manager/supervisor and verbally

reports the incidence prior to filling out the variance report b. Manager/Nursing Supervisor after notification by staff, immediately contacts the administrator on duty or on-call and verbally reports the incident d. Completing the Variance Report I. Stamps the paper II. Completes the following General information Occurrence type Brief description Immediate action Implementations Referrals to other departments III. Staff member completes the MD Implementation/Recommendations IV. Documents the progress note in the patients chart V. As warranted, the physician documents the findings and treatments in the chart Distribution StaffManagerChief NurseDirector Performance Improvement of