Frequently Asked Questions (FAQs)

General Questions

What are the benefits of completing the assessment and submitting data to the PPPSA project?
For practices that complete the self assessment and submit their results, the project will be of significant assistance to physicians, medical practice administrators and practice staff who seek to identify areas of potential patient risk in their organization, so that leadership support can be sought for improvements in these critical areas.

The project will provide MGMA, ISMP, HRET, and others with the ability to identify common areas of risk in medical practices and offer practical system improvements, including those that are thought to provide the highest leverage for overall risk reduction and improvement in patient safety.

The collection and aggregate analysis of data from a national sample of physician practices will also enable the medical practice community to:

• Understand the current status of patient safety and the systems that practices have in place to manage patients’ care safety. Analysis of these data will be useful in advising medical practices about areas for potential improvement of patient safety, and will provide a baseline for measuring improvement over time.
  
• Equally important, the PPPSA project will collect and distribute, to physician practices, examples of improvements medical practices are making to increase safety and reduce risk so that other practices can learn from these examples. The PPPSA project will also find and distribute tools and methods that practices can use to improve the processes and systems that are used to manage medications, information, and other key aspects of care.
  

Also, it will be important for practices to examine their self assessment results and to consider improvements in particular areas. Comparing the practice’s results to the aggregate results may help identify those areas. The PPPSA project will provide the aggregate results back to participating practices after the data are all received and analyzed.

A practice that performs a self assessment and submits data to the PPPSA project is likely to find areas that need improvement. Will this put the practice at greater risk for malpractice liability in the future?

It is likely that every practice that does a self assessment will find some areas that need improvement. Many of the items in the self assessment represent ideal or state-of-the-art practices, processes, and systems that will be a “stretch” for most practices. Doing the self assessment will enable practices to get a head start in improving safety and reducing risk of harm adverse events and future possible liability. Also, each practice’s self assessment results are submitted confidentially to the PPPSA database, and it is impossible for anyone at PPPSA to know a particular practice’s results, or to link the results to a particular practice. The data will be analyzed only in the aggregate, with benefit to all practices that participate in the project.

We are a highly specialized medical practice (e.g., orthopedic surgery or gastroenterology). Is the PPPSA assessment valid for our practice?

The self assessment has many items that will apply to essentially all medical practices regardless of size and specialty type. However, some items are more likely to be applicable to a primary care practice (e.g., managing consults from specialists) but others will be particularly applicable to a surgical practice (e.g., the use of anesthesia). To accommodate differences among practices, some of the self assessment items allow a “Not applicable” response. In addition, the PPPSA project team welcomes feedback from practices about new items that could be added to the assessment or how items could be improved, including modifications that would make items more useful to highly specialized practices. If you have suggestions, please contact us at pmr@mgma.com.

Assessment Questions

FAQ 1 (Question # 29.6)
Indications for medications are included on written and electronic prescriptions.

Why should indications be included on prescriptions and how should that be done?

Studies have shown that 25% of medication errors are a result of drug names that look-alike or sound-alike. Many look-a-like and sound-a-like medications are used for different indications. By including the indication on the prescription, dispensing errors can be avoided. Indications can be written on the prescription (e.g. Zyrtec, 10 mg, one tablet once a day for allergies), selected from a pick list, or included in the comment field with electronic systems, or by using prescriptions that include icons (e.g. pictures of lungs, heart, kidneys).

FAQ 2 (Question # 30.1)
When the practice transfers responsibility for the care of a patient to another physician, practice, or institution, the practice identifies the clinician responsible for accepting the patient and confirms that the clinician receives and accepts responsibility for the patient. Necessary clinical information about the patient is transmitted to the accepting clinician; the practice determines that the information was received. It is documented in the patient’s medical record that the patient has been transferred and that responsibility has been accepted by the receiving clinician, practice, or other institution .

What is “necessary clinical information”?

The necessary or essential clinical information that should be transmitted with the patient will vary. One example or suggested version is provided by the Continuity of Care (CCR) project, which was developed to organize and make transportable a set of basic information about a patient's health care that is accessible to clinicians and patients. The CCR set is designed to have information on transferring and receiving clinicians and key information about the patient’s diagnoses, problems, and condition, known allergies, medications, recent history including vital signs and laboratory test results, some information about planned treatment or testing, and basic insurance information. More information about the CCR can be found on the web site of the Medical Records Institute and the American Academy of Family Physicians website.

FAQ 3 (Question # 30.3)
The practice maintains a process to communicate all medications (name, dose, frequency, route and purpose) that a patient is receiving when the patient is admitted or referred to a hospital, nursing home, home care agency, rehabilitation center, etc.

What is meant by “process” in this question?

Each practice should provide or review a current list of medications including name, dose, route, frequency, and indication with patients at each practice visit. Patients and/or their caregivers should be instructed to share this list with health professionals when they are seen at a hospital or admitted to a nursing home or other short term or long term facility. The practice should maintain a current copy of this list and provide it to other healthcare professionals who may be treating or caring for the patient.

FAQ 4 (Question # 30.10)
For a patient for whom the practice has continuing responsibility, the practice has a process to learn of essential new information about the patient from outside the practice (e.g., new prescriptions and significant changes in the patient’s condition or plan of care) and to record them in the patient record.

What are ways the practice can learn about information on patients?

When a patient for whom a practice will assume continuing responsibility is discharged from a hospital or other facility, the discharge summary or similar information (such as that in the continuity of care record) should be provided by the discharging facility to the practice and to the responsible clinician. The practice may choose to establish a mechanism to anticipate such discharges and to ensure that this information is received from the discharging facility, in the same way that the practice will need to establish mechanisms to determine that it receives the results of outside laboratory and pathology tests and consultations.

FAQ 5 (Question # 31.1)
The practice has identified and communicated to all clinicians surgical and other invasive procedures that could be performed onsite. (Note: If the practice does not perform any invasive procedures then answer this question with “NA”).

What is the difference between surgery and invasive procedures? How are surgery and invasive procedures defined?

For the purposes of this question there is no difference between surgical and other invasive procedures in the office setting. All would require a determination by the practice of the ability to perform them onsite. Surgical or other invasive procedures are defined as those involving a skin incision or puncture including and excluding venipuncture or the placement intravenous catheters. In addition other specific examples of invasive procedures include but are not limited to:

• Biopsy
• Skin or wound debridement performed in an office setting
  
• Electrocautery of skin lesion
  
• Endoscopy
  
• Laparoscopy
  
• Injections into a joint space or body cavity
  
• Percutaneous aspiration of body fluids
  
• Central vascular access device insertion
  
• Laser therapy
  
• Dermatology Procedures
  
• Invasive ophthalmic procedures, including miscellaneous procedures involving implants
  
• Oral surgical procedures including tooth extraction and gingival biopsy
  

FAQ 6 (Question # 31.3)
The site of any surgical or invasive procedure to be performed for each patient is confirmed and documented by two staff members and the patient, before the procedure is begun. (Note: If the practice does not perform any surgical or invasive procedures, even in emergencies, then answer with “NA”)

What is the process for confirming the surgical site by the operative team?

Prior to beginning any surgical or invasive procedure, the operator and any assistants pause to check the identity of the patient, review the planned procedure and confirm that the operative site is the one that was planned by the operator and the patient. This formal “time out” is the final safety check prior to proceeding with the surgical or invasive procedure.

FAQ 7 (Question # 31.4)
Conscious sedation is only administered when two qualified personnel are in attendance and one individual monitors the patient while the second individual performs the procedure. (Note: If the practice does not administer any conscious sedation, even in emergencies, then answer this question with “NA”.)

How are qualified individuals defined? What are the characteristics of conscious sedation and how does it differ from other types of anesthesia?

Conscious sedation is a form of anesthesia that induces a minimally depressed level of consciousness. It allows the patient to maintain a patent airway independently and continuously and respond appropriately to physical stimulation and verbal commands. It differs from deep sedation and general anesthesia only in the level of consciousness maintained. All anesthesia requires close monitoring of vital signs, physiologic functioning, and the appropriate level of
consciousness.

Qualified personnel are those licensed practitioners who by education, training, and experience are privileged to deliver and monitor conscious sedation in the practice setting. In addition, it is important that each individual also have training to rescue the patient from deep sedation and that the practice confirm that ability through ACLS certification, written examination scores or process review proctored by an anesthesiologist.

FAQ 8 (Question # 32.2)
The practice maintains a system to provide continuing education to clinical and support personnel that is both specific and appropriate for the level of services provided in the practice.

How should continuing education be provided?

Continuing education may be provided internally by qualified staff in the practice or by staff attending programs provided outside the practice.

FAQ 9 (Question # 32.10)
The practice maintains separate policies, procedures, competency training, and continuing education programs for the treatment of pediatric patients. (Note: If the practice does not treat pediatric patients, even in emergencies, than answer this question with “NA”.)

Why is it important to have separate policies and procedures for the care of children?

Since children are not just small adults and have unique medical needs and requirements, which may not be appreciated by practitioners who care for an adult population, the practice should place special emphasis on their care. This emphasis should take the form of assessing the competency of the individual practitioner and support staff to care for children, assuring that resources relating to the care of children are available to all the staff, and that continuing education about pediatric care is offered in order to support the unique skills in pediatric care.

FAQ 10 (Question # 33.1)
A system of reporting errors (e.g. incident reports) is in place and is supported by a culture of safety that allows for open collection and sharing of the data within the practice.

Why is this important and what are ways to accomplish this?

A formal method for recording errors, such as incident reports, whether online or paper, provides a practice with the opportunity to document what happened, analyze the causes of the incident (e.g. root cause analysis when appropriate) and amend their process as needed to minimize opportunity for a similar failure occurring. In addition, regular and in-depth multidisciplinary review of these reports should take place to identify patterns and trends that could indicate larger systems issues that are at play, launch failure mode and effects analysis (FMEA) work within the practice and to facilitate the development of communications to provide experiential education to the practice staff.

FAQ 11 (Question # 33.2)
A protocol to report potential threats to patient safety and near-misses is in place, is known to all staff, routinely followed and supported by a culture of safety that allows for open collection and sharing of the data within the practice.

What is the value in recording incident and mistakes where a patient isn’t harmed?

Learning by uncovering possible error prior to harm occurring presents an effective opportunity for improvement by the practice. Examples of informal methods of recording “near misses” include glitch books, near miss reports, suggestion boxes, and narrative storytelling at staff meetings and brown bag lunches. It is also suggested that an organization have set a routine time to meet to share and analyze external and internal errors instead of waiting to meet and discuss errors only when something goes wrong (see FAQ for reporting).

FAQ 12 (Question # 33.4)

The published literature of errors and adverse events that have occurred in other locations is actively monitored, and the practice uses the information to proactively make system changes within the practice.

What are some effective tools to keep abreast of the literature?

Methods for monitoring include storing searches using the National Library of Medicine’s PubMed database and the “My NCBI” service to receive regular periodic alerts on defined subjects of interest, working with a medical librarian to generate individual bibliographies, or subscribing to newsletters, periodicals, listserv or web sites that provide literature announcements.)

FAQ 13 (Question # 33.5)
Patients are instructed on the proper use and maintenance of any devices prescribed or dispensed by the practice.

What types of devices or procedures require additional instructions to patients upon discharge from the practice setting?

Anytime a patient is discharged from a practice setting and is required to use a device to administer medicines, support a physiologic function or to provide ongoing treatment, the patient should be fully educated in the use of the device, its potential for failure and the proper maintenance to keep it optimally operational. In most circumstances, this responsibility for self care can be best accomplished by observing the patient use the device prior to discharge and when appropriate observe the patient perform routine maintenance and dispose of the device properly.

FAQ 14 (Question # 33.7)
The practice has protocols in place that are known to all staff and are followed on providing emotional support to clinicians and other staff members that have been involved in an adverse event at the practice and encourages staff to utilize it.

What are ways to provide this support to staff?

Practice should have established a relationship with an employee assistance program or other credible support resource that is skilled in responding to error support (e.g. Medically Induced Trauma Support Services (MITSS) in Massachusetts). Other processes for support could include trained mentors or preceptors that are available to both the general staff and individuals directly involved in the incident.

FAQ 15 (Question # 33.13)
Human factors and the key principles of error reduction such as standardization, use of constraints and redundancy are reviewed with all office staff during orientation and during each performance evaluation. 

What is meant by "human factors"?

Human factors (or human factors engineering) refers to the study of human abilities and characteristics as they affect the design and smooth operation of equipment, systems, and jobs. For instance, human factors analysis led to the now generally accepted recommendation that hospitals standardize equipment such as ventilators, programmable IV pumps, and defibrillators (ie, that each hospital pick a single type, so that different floors do not have different defibrillators) and more generally the principle that equipment be standardized within a system wherever possible.  This principle is also being applied within physician practices.  (PSNET glossary. Agency for Healthcare Research and Quality. Available at: http://psnet.ahrq.gov/glossary.aspx.)

FAQ 16 (Question # 33.18)
The practice utilizes established tools to monitor patient to staff ratio trends, flexible work schedules, sick day use and attitudinal / burnout for impact of staff fatigue, overwork and understaffing on patient safety.

How should a practice monitor staffing concerns that can impact patient safety?

A variety of tools exist that have been tested to gather data assessing culture and how it contributes to safety. In fact, this assessment may be used as a benchmarking tool for practices that seek to track improvements and changes in their safety work over time. In addition, establishing an executive rounding program will allow for staff to share their concerns with management directly.

FAQ 17 (Question # 33.19)
All practice staff are trained to recognize and manage health literacy issues.

How can practice staff access patient literacy?

Patients that have trouble reading and understanding health information can be difficult to identify. Behaviors to watch for that could indicate a literacy deficiency include: reluctance to read materials at the practice, inability to complete forms and lack of ability to name medications or explain their purpose. (Citation: Weiss BD, ed. Health Literacy: A Manual for Clinicians. Chicago; American Medical Association: 2003. Available at:
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf)

FAQ 18 (Question # 33.20)
The practice provides training to all staff in team communication including methods to ensure efficient and effective communication.

What are examples of effective communication and tools that support it?

Ineffective communication between caregivers has been indicated as a contributor to error in the hospital setting. Methods such as readbacks, walk rounds, process checklists, and morning briefings have all been utilized to increase the reliability of improving the information exchange between members of the care team.