Milestone 2 Project For NR 447

One of the recommendations for healthcare organizations to employ in an effort to reduce the number of errors is to advocate for voluntary error reporting nationally while conducting research and developing tools for patient safety. This way, information about errors can be gathered and prevented from reoccurring at health care sites and by health care providers. Voluntary error reporting will act as a warning of potential or actual errors and suggest ways to avoid them in the future.

The Healthcare field is becoming more aware of how important it is to change the way that organizational culture is becoming in order to help improve patient safety. Even though patient safety plays a very important part of our health care system which helps explain the importance quality of health care. However, when trying to keep patients safe, it can be a demanding challenge because of human errors and mistakes that are made. According to World Health Organization, patient safety is the absence of preventable harm to a patient while in the process of health care (who.int/patientsafety). Being in the position of a clinical content manager, the first step in reporting problems is to make sure that when reporting a problem, it need to be done at the earliest stage to show the importance to the company. The approach that I would take as a Clinical content manager is to identify the problem, have regular shift meetings to address any issues, flag any errors that occurred, have regular safety meeting, give feedback to staff on any errors that were found, try to figure out the best solution not only for the patients, but staff also, and although being a team leader, I would give the staff the opportunity to address any concerns that they may have.

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

Over the last 15 years or so a number of cases concerning patient care and safety have come to light prompting investigations and inquiries that have led to changes in the way care is delivered. These include inquiries at Winterbourne View hospital, Mid-Staffordshire hospital(Mid staffs) and Harold shipman to name a few.

In a world of budget cut and layoffs, medical corporations face new and different challenges in addition to helping and healing patients. I used to work as a medical biller in a physician’s office for five years and I experienced how difficult for the health care providers to get reimbursed. The government and the insurance companies have been limiting the budget towards the health care services. This action also affects the hospitals greatly because Centers for Medicare & Medicaid Services (CMS) and some policymakers have requested the hospitals to reduce the

The aim of the Affordable Care Act (ACA) is to reduce hospital readmission and to increase implementation of transitional care coordination for low health care cost. One benefit of establishing this

Partnership for Patients (PfP) has made significant progress in decreasing the number of preventable hospital acquired conditions (HACs), hospital readmissions, hospital patient deaths, and health care expenditures. Nonetheless, much work remains to be done so that PfP is more effective in their mission to make and improve care safety and care transitions. The progress made is part of a program that has been in effect since April of 2011, soon after sections 3011 and 3026 of the Patient Protection and Affordable Care Act (PPACA) were signed into law. These sections allowed then Department of Health and Human Services (DHHS) Secretary, Kathleen Sebelius, and Center for Medicaid and Medicare Services (CMS) Administrator, Donald Burwick, to create and provide funding through Medicare for a dual program to reduce hospital readmissions and transition care services.

Review of the Utah and Minnesota Incident reporting mandates provided various state statutes and reporting responsibilities to the state’s government and regulatory agencies. Reports of adverse events must be reported in various methods among states. For example, Utah and Minnesota require each individual facility, hospital, outpatient centers, and clinics, to report the adverse events that occur at the particular facility. Specifically, in Minnesota if the Boards that regulate physicians, nurses, podiatrist, physician assistants, and/or pharmacists are aware of an adverse event, the specific board holds the responsibility to report the events to the Minnesota Department of Health. Adverse events consist of defined elements within states in the categories of surgical, product or device, patient protection, case management, environmental, and potential criminal events, essentially providing events that produce irreversible patient harm. However, differences among these two states exist as Utah provides more specific descriptions in the case management events involving

In order to improve something, it must first be measured. Therefore, it is the safety policy of the Department of Veterans Affairs that incidents involving the safety of patients or staff members are reported and that the results of this reporting be trended nationwide to identify problem areas and opportunities for improvement.

Instead of providing the care they thought they would be providing, they were reigning in members to a program with the promise of improved health while they felt their own health was being neglected or jeopardized due to added stress, no time for breaks or guaranteed family time. Corporate compliance was called anonymously with complaints of working conditions and a state wide meeting was held with the RN case managers to gather information. Staff was assured that their concerns were being heard and efforts would be made to improve the current state of affairs.

A national reporting system, therefore, can usefully be regarded as a tool to advance public policy concerning patient safety.

Even though these readmissions appear to directly inflict adverse outcomes on only patients, hospitals are negatively influenced too because of rising number of rehospitalizations. Effective for discharges starting from October 1, 2012, in accordance with Patient Protection and Affordable Act, Hospital Readmissions Program established by Social Security Act mandates financial penalties for hospitals with excess readmissions (Centers for Medicare and Medicaid Services, 2016, para. 1). Within 30 days of discharge 20 percent of Medicare patients were readmitted and within 90 days of discharge, 34 percent were readmitted (Polster, 2015, para. 1). Substandard instructions about medications, teachings that is not patient-centered and the failure to provide contact information for any questions the patients have, are some of the factors that result in readmissions

The concern with not educating trainees before graduation is that incident and near misses tend to remain underreported because of the perpetuating negative culture surrounding error reporting. This in turn hinders learning from the event and stifles growth toward voluntary sharing of broken processes and system failures (Barnsteiner, 2011). The current focus on Quality Improvement is to provide high reliable care with little to zero risks by including the “combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development” (IHI, 2015).