Risk For Nursing Diagnosis

[music playing] [operator] welcome and thank you for standing by. at this time, participants are on a listen only mode. after the presentation we will conduct a questionand answer session. to ask a question at that time, please press *1 today’s conference is being recorded, and if you have any objections you may disconnect at this time. i would now like to turn the meeting over to dr. martin ruiz-beltran. [dr. ruiz-beltran] hello, thank you very much, and thank you for joining us. good afternoon everybody. i am a senior public health analyst

here with the bureau of primary health care in hrsa, and i welcome you to the bureau’s first audio conference. we are very pleased to have the opportunity to support your risk management activities, as we are committed to assisting you in thedelivery of super health care services to our constituents. we are continuing to listen to your feedback and your suggestions as with the recent grantee survey regarding the technical assistance trainingand specialized programming. hrsa is also committed to assisting you in enhancing your centers and operations and the delivery of health care services.

hence we have been working with you on the risk management and quality improvement and accreditation initiatives; just to assist you. together with our partners we are looking forward to providing you state of the art assistance and training and so this brings me to today’s audio conference. here with me today we have our partnersfrom the keystone peer review organization also known as kepro. and our partners from the ecri institute.kepro and ecri have been integral partners in the development of this risk management initiative. and we are pleasedto have some of the best well-known leaders in the field over of risk management, qualityimprovement and accreditation

working with us. so just let me turn to the stage to ms. amy goldberg-albertsfrom the ecri institute. she will lead us through the audio conference. at the end of the broadcast, we will entertainsome of your questions regarding this very important initiative. so thank you verymuch for joining us, and amy, please take it away. [amy] thank you dr. ruiz-beltran. and thank you to everyone for attending. i am dr. amy goldberg-alberts, director of the programclinical risk management resources provided on behalf of hrsa, here at ecri institute. 0:02:43.049,0:02:47.409i will begin with a couple of words about kepro and about ecri institute.

kepro, a quality improvement and care managementorganization, founded in 1985 and headquartered in harrisburg, pennsylvania, selected ecri institute to provide you free clinical risk management resources. kepro works with hrsa on medical malpracticeclaims reviews and risk management services under a contract initiated in 2004, and provide risk management and patient safety technical assistance to section 330, ftca deemed health centers and free clinics. ecri institute, an independent, non-profitapplied research institute, over the past four decades, has helped thousands of healthcareorganizations across the nation developed patient safety, healthcare quality, risk management programsto improve patient care.

our approximately three hundred patient staff is made up of physicians, nurses, patient safety, risk management,quality professionals, clinical engineers and others you see in red, on slide 3 the web address for the clinical risk management program website; which is a new repository for riskmanagement tools, resources and educational courses. you can learn more about these resources andlog into the website at http://www.ecri.org/clinical_rm_program

i will repeat that address later in the program. password access was sent to executive directors and unlimited users from each health center can be added. with your audio conference confirmation, you’llreceive an e-mail link to the slide handout. we hope you had the opportunity to printor download the slides. throughout this audio conference we will referto slide or page numbers in your handout so that you can follow along i’m now going to turn the program over to

kathy shostek. kathy is a nurse with 20 years of experience in healthcare risk management. the most recent of which has been focused on patient safety and healthcare error prevention. she has risk management consultative experience within the medical malpractice insurance industry, and management experience at the corporate risk management level of a large multi-specialty facility physician group. ms. jostic has served as the ecri institute’s chief risk management and patient safety liaision to the hrsa funded health centers and free clinics. kathy? [kathy] thank you amy and welcome everyone.

on slide 4, you’ll see the objectives for today’saudio conference. we hope you'll come away with a better understandingof the goals and the importance of clinical risk management, key aspects of a safe culture and knowledge of the top areas clinical risk, and we’ll go through some case studies for practicalapplication of clinical risk management. throughout the program we’ll mention resources at the clinical political risk management website. lastly we’ll open it up for questions answers.

slide 5, gives us the definition critical risk management it places special emphasis on identifyingcircumstances that put patients at risk of harm and it acts to prevent or control those risks. slide 6, reviews the goals of clinical with management which are to identify risks through the assessment of practices an operations and by reporting clinical near misses, incidents, adverse and sentinel events,

so that trends can be analyzed. all with the intent of redesigning processesand developing improvement strategies for preventing harm and reducing the potentialfor a similar event in the future. controlling systems and processes involve assessment, analysis implementation of improvement strategies and monitoring for effectiveness. risk control also speaks to reduce the severity of harm and to mitigate losses that are not prevented. slide 7, shows risk management as anongoing process, involving all levels of health

care delivery. it includes identifying and analyzing risks, collecting and implementing strategies to preventand control risk, and monitoring for effectiveness of those strategies. slide eight, is a busy schematic, but showsthe flow from identified risk to the setting of priorities and then the implementation of any numberof risk management techniques shown in the gray bar listing. the first technique is simply avoidance;

to avoid the risk. an example would be deciding not to providehigh risk perinatal services. the next two techniques work together to preventor reduce the risk by managing and controlling it. where the risk can be prevented 100% of the time, it's more realistic to reduce the probability orfrequency of an occurrence, and to minimize its severity. let’s give an example. it’s probably unrealistic to prevent all medicationprescribing errors, when a health center is providing primary medical care to a patientpopulation

that requires a range of drugs for treatment. however proprietors and centers can manage therisk of prescribing errors by taking steps to reduce the frequency where the probability oferrors and to minimize the severity of harm when they do occur. let's look at slide 9 for a moment. the world health organization (who) has advocated asystematic approach to minimizing poor quality and erroneous drug prescribing that focuses onspecific clinical steps for the prescriber to take. in addition, computers and other technologiesare available tools

for the prevention and reduction of prescribingerrors. this slide is meant to show you that information on who’s approach can be found at the web resource in the medication safety guidance article onthe clinical risk management website. let's go back to slide 8. we've mentioned what it is to avoid, prevent, and reduce risk. i should also note that when risk reduction,also applies to the claims management process and the concept of managing a claim

or a potentially compensable event to minimize harm or financial loss. at the bottom of the list is risk transfer. this is a risk financing mechanism totransfer risk, such as through insurance. we would be remiss if we did not mention thefour techniques listed in between as they are bonafide ways of treating riskand i'll mention them briefly later. however, in clinical risk management, prevention and reduction are the most widelyused.

taking a look at the feedback bar, feedback loop is necessary for continuous improvementin the risk management process. for example, if your health center implements an electronicprescribing system and as a means of preventing and controlling medication errors, the feedback would include monitoring how wellthe system is achieving those goals. moving on to slide 10, we’ll drill down on the risk management process,beginning with identifying risk. in its purest sense,

risk is an exposure to loss and maybe anynumber of types the losses. property losses, personnel losses, net income lossesand so forth. however the focus here is clinical risk. risk of harm to patients. an awareness on the part of all providersand staff on what creates unsafe situations, and places patients at risk of harm, is key to identifying risksin ambulatory health care. examples of risk identification sourcesand methods include proactive findings from risk assessments ofhealth center operations and practices, claims reports,

reports and trends of near misses, adverse events and unsafe conditions, accreditation or licensing surveys, medical records, clinical and risk management literature, resultsof risk root cause analysis, patient safety and quality improvement reports, and patient complaints and surveys. in order to help you identify risk, the clinical risk management website is designedto provide self assessment questionnaires,

toolkits and resource information through vehicles such as the risk and safety electronic newsletter. to demonstrate these resources let’s look at slide 11. here were showing a sample policy and form forhandling and documenting patient complaints what you see here are snips from the actual samplesthat you can find in the sample policy and tools section, of the clinical risk management website. moving on to slide 12,

we see that a comprehensive overall system also includes reporting on unsafe conditions as well as events and near misses. a reportable event can be anything that is not consistent withthe routine care of a patient or routine operation of the health center. an example of a reportable event is a medication error such as when a patient is given the wrongdose of insulin.

a near miss can be defined as an eventor situation that could have resulted in harm, but did not either by chance or through timely intervention. an example of a near-miss, is when the nurse practitionerrealizes that a tuberculin syringe was used to draw up a dose of insulin instead ofan insulin syringe and the error is caught before tenfold insulin overdose is administeredto a patient. unsafe conditions are any set of circumstances, exclusive of the patients own design a big process

has significantly increases the likelihoodof a serious adverse out come. an example of an unsafe condition is storing tuberculin and insulin syringesnext to each other. because they look similar without closeinspection the opportunity for error is significantlyincreased. a sentinel event, also known as a critical event is defined by the joint commission as anunexpected occurrence involving death or serious physical or psychological injury or the risk there of.

an example of a sentinel event. could be that a tenfold overdose of insulinis administered, the error is not detected and the patient discharged and experiencing hypoglycemic coma. slide 13 analyzes risks that have been identified. analysis of identified risk helps

detect trends and similarities in events that place patientsat risk of harm and establish priority for treating varioustypes of risk. simply put, the goal of analyzing risk is toprioritize and estimate their impact. after analyzing and prioritizing risk exposures, actions can be taken to make improvements in-patientcare processes and modify risky circumstances or risky behaviors that can lead to harm or liability losses.

these actions are risk control measures. as an example. because liability claims and ambulatory carefrequently involve a breakdown in the diagnostic testing process and since providers order laboratory testingin thirty to forty percent of patient encounters the testing process can be considered ahigh volume, high risk and therefore a priority for prevention and control. slides 14 and 15 list those technicalterms for risk control techniques previously mentioned

in the schematic back on slide 8. i’ll briefly give a few examples we’ve already talked about avoidance, prevention and reduction, so an example of segregation of loss exposuresmight be to establish satellite pharmacies instead of relying on one centralized pharmacy to dispense medication. moving onto the next slide. an example of separationof loss exposures could include

something like storing medical suppliesin two separate buildings. an example of duplication of loss exposure iscommon for information technology access when electronic data is backed up and stored off site. and an example of contractual transfer forrisk control would be the use of a hazardous waste contractor to pick up and dispose of hazardouswaste. shifting to selection and implementation ofrisk management strategies we move on to slide 16. when selecting strategies, health centers need to considerthe readiness of the center to

support process improvement the ability to provide ongoing education to staffand providers and risk management and patient safety. and the ability to monitor and report on theeffectiveness of their program. implementing risk management strategies involve education, agreeing on the specific scope of preventionand control strategies, deciding how they will be implemented, and who is responsible for carrying them out.

if reported events or claims involve communicationsfailures that lead to delays in scheduling visits for follow-up care, the health center should implement strategies toimprove communication and the flow of information. slide 17 is meant to show some information that the clinical risk managementwebsite has been loaded with guidance articles, that include numerous web resources like theone pictured here to help you with selecting and implementing riskmanagement strategies.

also, standards and guidelines, education and training materials, for you to use in developing your risk managementprogram. the next slide, slide 18, reviews the laststep in the risk management process, monitoring. monitoring answers the question, “are the techniquesworking?” this involves, setting performance target or standards, comparing results with expectations, and endearing to correct the gap between the targetand the actual performance.

your health center can use the self assessment questionnairesat the clinic risk management website as tools to assist in the monitoring process. let’s go on to slide 19. at this point we transition to patient safetyand the systems necessary to prevent and mitigate errors that can result in patient harm and liability. also i'll be handing it over to amy, who will discussthe culture of safety and its importance to clinical risk management. amy? [amy] thank you so much kathy.

beginning over a decade ago with another instituteof medicine report called “to error is human”, like many other industries the health careindustry has embraced a systems approach to patient safety. research since that time, continues to demonstrate how most health care errors are cause not by individuals alone, but rather by the breakdowns of systems and processes. likewise, improvements are seen byimproving systems and processes as opposed to focusing blame and remediation on individuals,

without fixing the underlying systems and process issues. slide 20, further elaborates on what exactlyis a culture safety. patient safety is listed by the american societyfor health care risk management as one of the top four functions for health care risk management professional today. embracing a culture of safety means patient safety is a strategic goal and acore value using a systems approach, as recommended by the institute of medicine,

recognizes that humans are not perfectand never will be. a systems approach also holds that human error is often a symptom of system problems and that human error alone usually is not the root cause of the adverse events or health careerrors. it is incumbent on health centers and providers to facilitate the redesign of systems, to reduce theprobability human error. in what’s known as a just or fair culture

providers of staff are held accountable for the thingsunder their control. for the management and administrative team,this includes system design. for the entire workforce, providers and staff, this includes individual behavioral choices. the means to risk control is safer patient care. and so it follows, that risk management is not the job of one individual, rather an organization that embraces a culture ofsafety. risk management and patient safety is everyone'sresponsibility.

a culture safety should be a strategic goal and a core value built in for every health center and everyservice provided by that health center and its clinicians. so how did the best organizations operationalize this? they embrace risk management and patient safety as everyone’s responsibility. they engage in proactive identification of unsafe practices.

mistakes are openly discussed. they embrace a just or fair culture in response to errors. they embrace a systems approach to improvementas opposed to an approach directed solely toward individual workers or individual clinicians. the next slide shows you a decision making modelfor responding to patient safety events and errors within a just or a fair culture. there is very good evidence that blaming individualsfor adverse events does little to improve patient safety. errors occur within systems

and we can redesign systems to reduce the opportunityfor human error. making decisions about how to respond as anorganization, the individual behavior can be guided by a just culture. one which embraces fair minded treatment and creates effective structures that helppeople reveal their errors and help the organization learn from them. the challenge of a just culture is balancing thefine line between appropriate actions in cases of egregious, dangerous or willful misconduct or deliberateviolation of rules.

and the much more frequent breakdowns incomplex systems involving fallible humans. the model shown on this slide gives concrete guidance for making fair or justdecisions about that behavior. the model shows where discipline is appropriatefor example, reckless or intentional disregard for patient safety. it chose the gray area. for example, a near miss occurs due to a minor deviation from process or policy.

and it shows when a blame free response is appropriate, such as when an employee makes an error while followingorganizational policy and process. i encourage you to print out this model and think about how your own organizationresponds to errors and whether it’s consistent with what’s known in a just culture. involve your operational managers, your risk manager and human resources in this discussion. this theme is continued on slide 22.

no news is not good news in the world the patientsafety. and an organization with a strong safety culture views errors as treasures. when evaluating the culture of your health center, think about, not only what is said in mission statementsand the like, although these are important, but the way things are actually done around here. culture describes how new employees learn how thingsreally are done, as opposed to the policies, procedures, actions, language, and marketing that an organization mightengage in.

employees, and patients, as well are quick to be aware of when there is a differencein what is stated verses what is reality in well managed healthcare organizations it is congruent between policies and procedures, language and behaviors. when you begin viewing errors as treasures, you might want also need to explain to your board why the number of reported problems might berising.0:23:42.140,0:23:44.060,0:23:45.550the risk of patient harm is not rising to the contrary, the risk or the probabilityof actual harm could be going down

because the underlying problems are comingto light and are being addressed. moving on to slide 23. other characteristics of a strong safety cultureinclude job descriptions and responsibilities that incorporate safety principles, safety as a criteria in budgeting and purchasingdecisions, where there is an openness about errors and problems, and incentives reward reporting errors, not the absence of errors. and now i’ll hand it back to kathy who will talk about trends

seen in federally qualified health centers, and who will present some case scenarios. kathy? [kathy] thank you amy for that excellent overview ofa culture of safety. now, let’s move to slide 24 and focuson the top areas of clinical risk for health centers and clinics. when professional liability claims are reviewed they’re classified by the nature occurrence. and these are the top areas involved in occurrencesleading to liability claims in health centers and free clinics.

the information is extrapolated from kepro’s 2009 annual report for hrsa. diagnosis related claims involve thins likea failure to diagnose or a delay in diagnosis. obstetrics claims include a failure to identifyfetal distress, it could also include things like improper managementduring perinatal care, or improper performance of a procedure. claims can involve either the mother or babyor both. treatment related claims include allegationssuch as failure treat and improper management or treatment.

medication related claims can include things likethe wrong medication being ordered. while we know that prescribing errors account for the highest number of medications errors in ambulatory care, errors can occur at anypoint in the complex process of medication use, including dispensing, administration andmonitoring. surgery related claims often focus on improperperformance and elude to issues with surgical technique, although there are many other issues seen in surgical claims. now, in the next series of slides, we will reviewtwo case studies and point out some the risk and safety issues and recommended risk managementactions.

in the first case example on slide 25, a patient calls to report that he woke upfeeling weak this morning and asked to be seen in the clinic that day. the appointment schedulewas full, and the front office clerk does not ask any additionalquestions about his complaint, but she informs the nurse about his call. after a delay, the nurse calls the patient back. he’s a 68 year old man with hypertensionand hyperlipidemia, taking lisinopril 20 milligrams daily for the past year, hydrochlorizide 25 milligrams added three days ago.

she informed the primary care provider of his call,his complaint of weakness and his request to be seen today. attributing the weakness to the hydrochlorizide,the physician tells the nurse to call the patient and tells him to stop taking the hydrochlorizide. but the nurse decides to tell the physician that sheis concerned because the patient sounded anxious on the call and that he was reported feeling like his heart was beating out of his chest. on slide 26, we see that with this new information, the physician decides to have the patient come in for an electrocardiogramand a blood pressure check. the patient comes in

one hour later and is diagnosed with new onsetatrial fibrillation. he's subsequently admitted to the hospital and cardioverted without complications. this could be considered a near-miss. it presents several opportunities for learning and implementation of preventive strategies. by reporting this near-miss, risks are being identified. analysis of the situation can reveal unsafebehaviors, communication successes or failures, or teamwork actions that could be improved. preventive strategies could be implemented and a higher level of risk control achieved.

the following are just two of the areas in this near-miss case example that could be a focus for risk management. let’s go on to slide 27. the first area is inadequate triage, failureto question the patient. front office personnel should have clear guidelinesfor telephone triage and notification of clinical staff when an emergent or urgent situation arises. a delay in evaluating a patients complaintis clearly a risk to patient safety. but the risk management action is to provide triage trainingin guidelines to the front office clerk. a sample form of questions that staff might asktriage patient calls

is available in sample policies and tools sectionof the clinical risk management services website. on slide 28, we see the second area in the near-misscase example, communication success! when the physician orders the medicationdiscontinuation, the nurse speaks up and conveys her concern regarding the patient's condition. she offers the provider additional, importantinformation, to help the patient care decision making that results in safer and more prompt carefor the patient. had the patient not been brought in for cardiac evaluation,

his condition may have deteriorated, resultingin adverse outcome and a potential liability claim. so the risk management action is to tell the story,celebrate the success and re-enforce effective communication between health centerstaff. on slide 29 is our second case example. an 82 year-old man with cardiovasculardisease, prior cabg surgery, taking coumadin, was followed by his primary care physician. he had four visits to the hospital within one month.at each time he was ordered antibiotics or cystoscopy, urinary tract infectionand respiratory infection, and other complaints.

about a week following the last hospital visit, the patients son brought him to see the primary carephysician, reporting that his father was confused, confused, and falling asleep. the provider noted that the patient failed amental status exam. moving on to slide 30, we see that the patients last inr had been done two weeks prior to this visit,so the provider instructed the patient to follow-up with the coumadin clinic. the documented impression by the provider wasnumber one, that was a change in mental condition condition and number two, throughout the cerebral-vascularaccident.

orders included blood cultures and a ct scan as soon as possible.0:30:29.920, 0:30:35.450however, the ct scan was scheduled to be done infive days time. three days after this visit, the patients family brought him to the emergencydepartment because he was slurring his speech. a ct scan was performed, revealed a subdural hematoma, including areas ofactive and older bleeding. the patients inr was 3.8, well above the target range, indicating his bloodwas overly thin and that it was at risk of bleeding. following transfer to a medical center, the patient underwent an emergency craniotomy,

after which time he remained comatose. moving on to slide 31, his family elected to limit treatment to comfortmeasures, and he died within a few days. a court found the primary care provider negligentand awarded damages any amount of $150,000 to the patients estate. on slide 32, we note just some of the risk management issuesin this case. the first, a failure to order an immediate ct scan and an inr.

the provider ordered the ct scan as soon as possible,but it’s unclear what that meant. stat? today? immediately? the risk management concern, are to standardize the terms for urgent diagnostic testsand consider using confirmation feedback. confirmation feedback is restating communicatedinformation, to clarify its meaning and to confirm that it was understood. a standard operating procedure would be forthe staff member responsible for scheduling tests, to confirm the urgency of the test and tocommunicate back to the ordering provider, if and when there are scheduling issues affectingcompletion of the test.

on slide 33, other risk management issues include unsafe hand-off, and ineffective communication. because coumadin is a high alert medication there is a duty to ensure that the patient isbeing monitored. it's unclear to what degree the primary providerand the coumadin clinic were coordinating the patient anti-coagulant therapy. the risk management action would be to implement astandardized handout process in which information about the patients care is transferred and communicatedin a consistent manner.

you’ll find a link under the standards and guidelines section on the risk management website to a resource, again from who on communicationduring patient handovers that may be useful in this area. and the second risk management action is to providewritten instructions and ask patients to repeat them back. a sample format that was developed by the ecri institutefor providers to use as a tool for communicating and documenting care provided and instructionsgiven in the outpatient setting is availableunder the sample policies and tools section slide 34 is a screenshot of the website

where you can find the tools and forms mentionedin today’s program. on slide 35 we note that this audio conference and wide presentation handout, will be archivedon the clinical risk management website for future listening. the url for that website is:http://www.ecri.org/clinical_rm_program physicians and other providers can also participatein the course, clinical risk management basics, and potentially obtain cme credit for successfulcompletion by registering and logging onto ecri institutes elearn system. this course will be available beginning in mid-march.

this concludes the program, but we will takequestions in just a moment. first we'll ask the operator to conduct ourparticipation poll. operator? [operator] thank you. at this time, we are ready to begin the polling session. there will be one question. after the question has been asked, please respondby pressing star, followed by the appropriate digit on your phone. you will hear a tone upon making your selection. how many people are in the room, including yourself?

please press *1, for one. *2, for two. *3, for three. *4, for four. *5, for five. *6, for six. *7, for seven. 0:35:10.689,0:35:13.249*8, for eight. and *9, for 9 or more. thank you, this does concluded the pollingsession.

[amy] thank you. at this time, i’ll hand it backover to dr. ruiz-beltran, for closing comments0:35:30.649,0:35:33.179and then on to questions and answers. 0:35:33.179,0:35:36.869[dr. ruiz-beltran] thank you so very much. whata wonderful presentation. as you can see we are very excited about thisinitiative. the information here in clinical risk management is outstanding. and we are looking forward to hearing from you, from your comments, to answer any questions you might have. so, at this point, let’s just open it for questionsand see how we can help you. operator please? [operator] thank you. at this time we are ready to begin the question and answer session. if you'd like to ask a question pressed *1. please un-mute your phone and record your first andlast name when prompted. and to withdraw your question, you can press *2.once again, if you'd like to ask a question,

please press *1. one moment please for the first question. once again, if you’d like to ask a questionplease press *1. we do have a question, one moment please. our first question is from carla felcher. [carla] hi, can you hear me? [operator] yes, yes. [carla] okay, alright. the question i had was about getting additional passwords for our quality manager our nurse manager or our medicaldirector.

i know you say you can get unlimited ones, but how do you go about doing that? [amy] yes. the executive director, of every health centerhas been sent, what’s called an invitation, in order setup his or her own userid and password. that individualthen gets set up as what’s called an access manager. and they can then and given unlimited number ofpasswords to anyone within the health center. they can also switch the.. the executive director doesn’t need to remain the access manager. that can be switched. the invitation comes from the web address helpdesk@ecri.org and in order to switch the access manager tosomeone else,

again you would email that same address helpdesk@ecri.org [carla] thank you. [operator] okay, thank you and the next question is from betty. [betty] yes. hello. i am calling here from a clinicin san jose, california. we are in a clinical setting and it sounds likeyour lecture was on pretty much, referring to a hospital.do you have any lectures or any other material that would be on along the lines of a clinicalsetting? [amy] uh... what type of clinical settingare you in?

[betty] basically, actually, it’s a non-profit.we have five clinics and we pretty much have dental to pharmaceutical and pretty much, adults and pediatrics. and we do have a pretty large population of patientsthat we see. [amy] yes. the clinical risk management websiteand presentation, was in fact designed for outpatient care. so, i think you'll find once you are onthe website that it devote to outpatient ambulatory care, whether that’s clinic or uh...otherwise. a variety of populations are also addressed.the two clinical examples that we used

were adults but there certainly will be other populations that will be addressed in other sessions in the future. [betty] okay, great. okay, thank you. 0:39:29.849,0:39:34.139[amy] thanks a lot. 0:39:34.139,0:39:41.139[operator] thank you once again, it’s *1 if you’dlike to ask a question. one moment please for the next question. barbara lynn hart, your line is open. 0:39:58.029,0:40:01.970[barbara] hi, thank you. i am in an fqhc in brockport, new york which is up near lakeontario. we are a rural site on one of our big issues is patient compliance. you know, unlike a hospitalsetting where you can clearly follow-up, and you’ve got a laboratoryat your services, if a patient chooses not

to have an x-ray or lab work or go for their inr, are they’re going to be presentations in the future on howto deal with those compliance issues and documenting those lack of compliance issues? [kathy] sure. and i think you’ll also find someresources at the website that focus on those types of problems. but, we'd like the feedback and we’ll certainly tryincorporate more on that type of issue for the next session. [barbara] thank you. [operator] are we ready for the next question?

[amy] yes. [operator] thank you. dr. ali your line is now open. [dr. ali] yes, hi. i heard what you said about gettingadditional password and codes, but what if our executive director doesn't have the email, can't find the email,for whatever. we just have him email the helpdesk@ecri.org again? [amy] yes. we will certainly resend that invitation. so, if you will email helpdesk@ecri.org, pleasebe sure to put the name of health center and the name of your executive director would be helpful as well. [dr. ali] okay. now does he have to do it or can i as the chief medical officer do that?

[amy] you can send that email as long as you givethat information along with it. [dr. ali] okay, great. [amy] great. thank you. [operator] the next question is from george van buren. [george] well, i guess mine is that same question that was asked before. i tried to click on that link that was provided by my ceo and it says that it wasunavailable, so i was having trouble getting access to the password,so i think if i just email the helpdesk that they could probably provide that information for me.

[amy] exactly. [george] now, let me just follow-up real quick, for cmecredits for this workshop how does one go about being compliant with that? [amy] yes, this particular program for the live audio, there is no cme connected with thisprogram, but there will be a program called clinical risk management basics hosted for, in the elearning system, its learning management system. it’s ecri institutes elearn system. and once yourexecutive director gets the course keys

they will provide you with those course keys togo in and actually take the course for cme credit. [george] so is that the same as getting the passwordsto access the ecri website? [kathy] no, not exactly. actually, the course keys aregoing out today, 0:43:03.130,0:43:05.659to all of the executive directors. and on the website, there is a learning managementsystem. there are two course keys. one for core courses and one for a supplementalcourses. those course keys will get you into this particular program that’s going to be developed and posted in late march as a cme course.

okay, also, just so that you know, this program, just as you are hearing today, willalso be posted on the website for general listening. so it does not have to be taken as a cme course.it can be either way. it can be taken four cme or it can be listened to for general listening for the rest of your staff. does that answer your question? [george] yes ma’am.[amy] thank you. [operator] the next question i believe is from frankie nunez?

please check your mute button. mr. nunez? not getting a response. one moment for the next question. sarah fry your line is open. [sarah] hi. forgive me, i don’t want to belabor the point butwith the passwords, my executive director went in and setup her profile and all, but, does she have to login? and is there a spotwhere she issues the passwords? it wasn’t clear and i emailed afterwards but i hadn't heard back yet, so i thought i’d ask.

[amy] yes. if you go to, i think this will answerthe question. if you go to,http://www.ecri.org/clinical_rm_program at that website, is where the space is for entering your userid and password. [sarah] right. [amy] so that’s where you login. 0:45:27.109,0:45:29.669[sarah] right. so she logs in, but where do… how does she assign the passwords? [amy] oh. to assign the passwords, that is through something called the access manager andinstructions for that should be sent out

if they have not already been, to your executivedirector. oh. there are also posted. if you go to that website:http://www.ecri.org/clinical_rm_program the instructions for that access manager, how to add passwords to the group. those are posted. the instructions are posted. [sarah] excellent. thank you very much. [amy] thank you. i hope we answered your question. [sarah] thank you. 0:46:12.989,0:46:19.430[operator] okay. one moment please for the nextquestion. marty heller, your line is open.

[marty] hi, thank you. i’ve had several free clinics that have requested an instrument to conduct riskassessment. is there such an instrument on the website? [amy] yes, there is. under the self assessmentquestionnaires, which is under the guidance area of the website, there is a patient safety and risk management questionnaire. it’s available in a pdf and a wordformat, so that you can download it and use whatever sections for appropriate to your clinic. [marty] thank you. [amy] you’re welcome.

[operator] once again, if you’d like to ask a question, please press *1. [dr. ruiz-beltran] if we don’t have any more questions at this time, we can receive them if you send us an email. i will be glad to answer it. or if you haveany comments or feedback you want to give us regarding this particular audio conference, we would be glad to respond to you. if there are no more questions than we will say thank you once again, and this will conclude our presentation today.[operator] sir we do have one more question. [dr. ruiz-beltran] please, thank you.

[operator] jorge, your line is open. [jorge] thank you. just a quick question. you were talking about educating the front office staff about phone triage. do you recommend recording phone calls? triage phone calls? [kathy] if you're going to record calls, the patientneeds to know that they're being recorded. if the patient consents to that, that’s okay. [jorge] okay. but for risk management do you recommendthat it's done?

[kathy] no. no we don't recommend that. [jorge] do you recommend documenting the call on paper?0:48:41.769,0:48:47.259[kathy] yes. that’s a good idea if you're able to do that.if you have the wherewithal to record calls, that’s entirely up to you, but it is a consent issuewith the patient, so. either way would be certainly acceptable. [jorge] okay. well thank you very much.[kathy] sure. 0:48:56.440,0:49:03.440[amy] and for everyone’s benefit i’ll read the emailaddress and phone number so that everyone has additional questions please feel free to be in touch with us.the email address is clinical_rm_program@ecri.org. the phone number is 610-825-600, ext. 5200 thank you everyone for joining us.