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Clinical Practice Guardrails: Role of QA and Documentation

in Patient Care

Jonathan W Gietzen MS PA-C

Department of Family Medicine

Kaiser Permanente

Hillsboro, OR

Lecture goals

� Understand the role and process of Quality Assurance Committee

� Review common clinical reasoning errors

� Review common charting tips to strengthen patient care and reduce risk for error

� Disclosure: I have no conflict of interest in relation to the content presented in this lecture.

Qualifications

� Nearly 33 years in ICU/hospital, home health, primary health care

� Care provider, shift lead, manager, educator, administrator, researcher, published author

� Kaiser Permanente Regional Adult Primary Care Quality Assurance Committee

� Kaiser Permanente Systems and Safety Committee

� Two QA investigations into my practice as a PA in 18 years.

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QA Process

� The peer review process is a mechanism to evaluate potential quality of care concerns to determine whether standards of care are met and to identify opportunities forimprovement. The process is used to monitor and facilitate improvement at the individual practitioner and system levels to assure safe and effective care. (KPNW)

� The QA process is;

� Not punitive

� A mechanism to reduce

� Near misses,

� Misses &

� Sad outcomes

Scoring

�P0/S0 care is acceptable

�P1/S1 Minor/moderate opportunity for improvement

�P2/S2 Significant opportunity for improvement and/or care deemed inappropriate

Quality Care Wall

0 brick= P0, 1 brick = P1,

2 or more bricks = P2

Appropriate Technical Expertise or Consultation

Adhered to Evidence Based Guidelines

Correct and Timely Tests and

Therapy

Effective Communication

Adequate Documentation

Suggested Defense: Routinize each behavior for each basic encounter you perform

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Doing Same Thing = Same Results

Suggested Defense: Rule of Three

Substitution Test Algorithm

Evaluate for possible system

errors

Does not Merit peer review =Done

Merit peer review, if YES, Review possible

system and documentation

issues

Within standard of care? Done

Not within Standard of Care

Pass Substitution Test?= Yes

Clinical Risk Low = P1 Clinical Risk High = P2

Pass Substitution Test? = No

Clinical Risk Low= P1

Clinical Risk High = P2

Suggested Defense: Ladies and Gentlemen of the Jury

Your Response To QA Inquiry

�To do

�Check with supervising MD/Mentor

� Timely response

�Don’t hold back, be honest

�Avoid

�Cagey responses

�Not answering the questions asked

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Your Response To QA Inquiry

�QA is not punitive, However You can get in trouble when; �A clear pattern of behavior has

been identified which puts the patients and organization at risk from this clinician

�Given opportunities to improve and then not show improvement

Common QA Themes

� Poor Decision Making

� Room Dynamics (strong personalities, multiple c/o)

� Inappropriate delay in ramping up care, delay in dx

� Lone Wolf Disease

� Not respecting medications

� Weak Differential Diagnosis, esp with hot potato pts.

� Not putting VS and exam into appropriate context

� Documentation is weak or omitting key components

Common Clinical Traps

� Diagnostic Errors

� Intuitive- Type I

� (Premature closure)

� Focus on the case not past hx, put pt symptoms first

� This is a case of _____ (sx) , in a ____ (age) , ______ (gender), with a past history notable for ____, _____, ______

� Over-analytical- Type II error

� If you gather enough information any clinician can make pt fit their pet diagnosis

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Common Clinical Traps

� Diagnostic Errors

� Seen by Multiple Providers

� 3 strike you’re out rule (Swiss Cheese)

� Too many cooks spoil the broth

� Over-dependence on specialist who may or may not see the patient.

� Specialists can be wrong, distracted, you may not have given adequate presentation, so wrong advice given.

� Bias- Race, Age, Habitus, Smoker, etc.

Common Clinical Traps

� Convincing patient

� Listen to the patient, BUT…..

� If pt is demanding a certain treatment because ‘It always is my ____ and I need you to do _____’ (take a step back and verify information.)

� Does more information need to be added to confirm dx?

� Look for consistency in their history and exam to confirm what they are saying.

� Is there a competing diagnosis which can be substituted.

Common Clinical Traps

� Frequent Flyer (easy to rubber stamp and move on)

� Consider acute on chronic and delineate the difference

� Consider natural history of disease

� Consider medication reaction

� Consider that the condition may be true, true and unrelated (explain what this means)

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Common Clinical Traps

� Medically complex or pt outstrips ability to treat them with your resources.

� Sick people and medically complex people need to have current/baseline labs

Common Clinical Traps

� Not having pre-set boundaries, when in doubt;

� Talk over with colleague, MD then document conversation (avoids lone wolf disease)

� Develop rules for yourself

� 7-7-70 (7 dx, 7 drugs or older than 70 = greater risk)

� Pt in clinic/urgent care longer than 1 hr, have a good reason why. If not, then consider transporting out

� Never give pain meds for undiagnosed abdominal pain

� When you think pt no longer can be seen in this setting and needs higher level of care

� Use Clinical Rules, Pneumonia Severity Score, PERC, SIRS, Wells Criteria, etc.

Common Clinical Traps

� Multiple complaints

� Occam’s Razor, look for the unifying diagnosis which best explains patient’s symptoms. HOWEVER, not all symptoms are related.

� Get pt to list symptoms/concerns

� Prioritize which ones are of most concern to them

� Then prioritize which ones are of most concern to you

� You don’t have to address all concerns at this visit

� It is OK to take a stepwise approach to evaluating the patient

� This may take several visits to sort out all of your concerns, we are going to focus on this today as I am most concerned about ____.

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Common Clinical Traps

� Prescribing/ Monitoring Errors

� Pt requests medication, has not been seen, or did labs or ….

� If you can't monitor it, don't prescribe (refill) it.

� Diabetic, does not come in for their Hba1c, microalbumin, etc. gets refills for several years, has an MI, labs at admission Hba1c 12.

� HTN, does not come in for BP checks, continues to get his Lisinopiril, not seen for two years, has a stroke, BP at admission 220/130 mmHg.

Common Clinical Traps: RESPECT

� Renal excreted in pts with impaired renal or age > 60, check GFR/Creat, consider nonrenal med options, renal dosing (usually cut dose in half)

� E.g. NSAIDS in someone with renal disease

� Elevated liver function, avoid tylenol, alcohol, competing P450 meds

� E.g. LAMISIL in someone with Fatty liver and chronically elevated LFT

Common Clinical Traps: RESPECT

� Sedatives, (Anything that can increase risk for fall (muscle relaxer, anxiolytic, etc.)

� Flexeril in elderly, they fall and earn a C-4

� Pain medications. Opioids OD in younger pts, give smaller quantities, check psych history), limit long term, long acting opioids in the young, check for pts receiving meds from

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Common Clinical Traps: RESPECT

� Elderly, poly pharmacy, decreased ability to metabolize, multiple side effects, multiple co-morbids.

� Coumadin (interacts with everything, check INR when adding a med, notify ACC team when adding a med)

Common Clinical Traps: RESPECT

� Testosterone

� Secondary hypogonadism

� Screen questions may help identify a more likely cause for their desire to seek testosterone (OSA, obesity, MJ use)

� Rigid onboarding criteria

� Rigid monitoring due to multiple side effects

� Recommend involve endocrinology

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Testosterone Screening Questions

�Prior testosterone, iron, BMI, UDS

�Recent severe acute illness

�Loss of androgen-dependent body hair or change in shaving pattern

�Testicular atrophy

�Hx Testicular trauma or torsion

Testosterone Screening Questions

�Gynecomastia/breast development

�Marijuana Use

�Hx of Mumps orchitis

�Chemotherapy, radiation therapy

�Change in PERIPHERAL visual field?

�New headaches?

Testosterone Screening Questions

�Elevated iron levels?

�Problem with sense of smell?

�Untreated sleep apnea?

�Sleep disruption, shift work?

�Chronic narcotic use?

�Has ever fathered a child?

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Common Clinical Traps

� Poorly differentiated dx is a higher risk patient than almost any other pt.

� The sickest patient is the one without a diagnosis. Wacksman

� Common things are common

� It is more common to see an uncommon presentation of a common condition, than to see a common presentation of an uncommon diagnosis.

Common Clinical Traps

�“The patient can have as many diagnosis as they !@#$% well please.” Hickam’s Dictum.

Common Clinical Traps

�THREE plus a ZEBRA helps clearmind and focus on the encounter

� Include a realistic differential diagnosis in most notes

� If ‘hot potato’ include why or why not the diagnosis does not fit

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Common Clinical Traps

�Patients presentation does not fit with their CC

� Progressive LBP, now in w/c,

�Revisit diagnosis

�Ask for help, avoid lone wolf disease.

Common Clinical Traps

�“If you understand physiology, you can always pick the right answer” RiffatMorgan MD

Documentation Pearls

� Address CC even if CC per pt is incorrect (pt reports no SOB despite that being listed as their CC today)

� Look at any problem list, add things to problem list even if temporary

� Take credit for work you do

� If you interpret an x-ray, say so

� If you spoke to a colleague about case, document it

� If you and pt agreed to a plan that was non-standard, say so.

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Documentation Pearls

� If you cut and paste from other notes or sources

� You are responsible for that information in the note.

�Comment on this information

� Reference where information from (e.g. CareEverywhere, x-ray report, lab report, etc) include date.

Documentation Pearls

� Vital sign review and comment

� I comment on every VS for every patient.

� Look at trends, look at the graphics or tables.

� Examine the part complained of;

� Usually the system above and below, or

� All parts included in that body part (e.g. wrist would be skin, nerve, vascular, tendon, bone, muscle)

Documentation Pearls

�Diagnostic plan

�Therapeutic plan

�Contingency plan

�Anticipatory guidance

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Documentation Pearls

�Diagnostic plan,

� Labs or imaging to rule in or rule out

�Use established rules, (e.g. pneumonia severity score, Wells score, PERC, SIRS, etc)

Documentation Pearls

�Therapeutic plan

�Medication, therapy or other

�Contingency plan

� If not improved on this plan in 2-3 days, would CONSIDER….

Anticipatory Guidance

�Anticipate what questions may have about their condition. Address them up front;

� Reduces call backs

� Reduces repeat visits

� Reduces request for additional testing

� Reduces request for referral

� Increases pt confidence in your skills/dx

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Anticipatory Guidance

�Examples

� If you do prescribe it, make sure there are parameters on when to return, when to stop.

�Not unusual for a patient tx’d for pneumonia to have a more productive cough once infection clears. Explaining this will often save a call or clinic visit.

Anticipatory Guidance

�Pt sprains ankle, 3 days later had bruising into their foot

� Give advice bruising can happen due to gravity they are less likely to come back in

� If you fail to mention it, then they think you missed something

� They won’t trust the original evaluation

� May want additional testing or referral

Anticipatory Guidance

� Put in next step if pt does not improve

� Return for recheck if not improved in 2-3 days

� Call back in 2 days…

� If worsening or develop new or other concerning symptoms, be seen sooner

� If you feel your symptoms are significantly worse, go to ED

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Anticipatory Guidance

�Document why varying from care

� If patient declines, document this, (and/or order test anyway to show that you knew what next step was)

� If making a palliative care decision include discussion in your note (include who is in the room as well, if possible their names and relationship to pt)

Anticipatory Guidance

� If your plan is close follow up

� Make sure they get an appt scheduled,

� Have a back up plan if worse between now and the future appt

� If significant concern, you send a tickler to yourself to call pt or remind pt if they do not come to the fu appt

�At every point, try to close the loop where pt care may suffer

Lecture goals

� Understand the role and process of Quality Assurance Committee

� Review common clinical reasoning errors

� Review common charting tips to strengthen patient care and reduce risk for error

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