This is Waiting to Be Seen 10 on EM Cases – EM Quality Assurance Part 2: Individual Responsibilities.
Written by Lucas Chartier, edited by Howard Ovens October 2016
Last month in introducing part one of our guest blog on quality assurance I told a story about a missed opportunity with follow-up care. This month I’d like to share a story with a happier ending. Recently, a patient presented at our emergency department with a non-specific fever. After discharge the patient’s blood cultures were reported positive, but attempts to reach this person over the ensuing 36 hours at the contact numbers provided were unsuccessful. An enterprising colleague googled the patient and found contact information online that eventually led to a call to the patient in a hotel room in another city, but when reached the patient was ill and confused. Undeterred, our enterprising doc got help for the patient through the hotel’s front desk and even alerted the local ED about the situation so the patient’s care was optimized on arrival. The patient later sent me a heartfelt letter thanking everyone who had persevered in reaching them and likely saved their life. The hero of this story is my colleague who went above and beyond our usual protocols to help a patient.
Another time, several diligent emergency physicians were working with a patient to address some positive cultures for sexually transmitted infections that had come as a complete shock. The third physician to get involved listened carefully to the patient, put on her deerstalker hat, and went “Sherlock Holmes” on the case. She discovered the samples that led to the diagnoses had been mislabelled—and the patient’s faithful partner was allowed out of the doghouse.
These stories remind us that in any system, no matter how well designed it is, we are still dependent on the conscientious and creative actions of individuals to maintain high standards for quality. One of my staff changed my personal practice a few years ago; I asked her how she had found a couple of instances of quality assurance system failures in the care of her personal patients. She told me that “just to be careful” she checks most radiology reports personally when she does the coding/billing of her charts a few days after her shifts. This allows her to get feedback on her cases and find an occasional quality assurance lapse or difference of opinion with her colleague, who reviewed the report as part of our official quality assurance process. This makes great sense to me and I’ve done the same thing ever since with my own charts.
In part two of this blog on quality assurance, Dr. Lucas Chartier, an emergency physician in Toronto, will review the roles and responsibilities of the individual physician within an ED and its particular quality assurance system.
—Dr. Howard Ovens, October 2016
Assessing Your Own Quality Assurance Duties
(and what your ED’s QA policy says about your workplace)
Not long ago, I returned to the hospital after a few days off only to realize—to my horror—that I had missed a subtle fracture on a foot X-ray. I started to panic and think of all the possible things the regulatory body in my province was going to reprimand me with, only to remember that my hospital has an effective quality assurance process that deals with discrepant radiology reports (and microbiology results). The staff radiologist had flagged the patient’s X-ray as “needing review” due to my preliminary diagnosis of “nil acute,” which was dealt with the next morning by the daily quality assurance shift physician. The patient was called, instructed to buy a walking boot, and advised to follow up with our fracture clinic. I had been saved by the system (and excellent, dedicated colleagues). But what if my hospital hadn’t had this quality assurance process?
As emergency medicine providers, we make countless decisions with limited or incomplete information (or less than gold-standard diagnostic capabilities), with the final answers from tests often available only after the patient has been discharged from the ED. This includes final staff reads on diagnostic imaging tests and microbiology results. In part one of this blog I discussed the various challenges that this situation poses, as well as my ideas on how to develop an effective, reliable, and safe quality assurance system for your ED.
But regardless of whether your hospital has or does not have a formalized quality assurance process, what is your personal responsibility in the matter—both medico-legally and ethically? And what does this say about the ED where you are considering picking up shifts?
In this blog, I will offer my thoughts on these challenging issues to help both front-line physicians and ED leaders provide the best care possible to their patients.
My ED does not have a quality assurance process: What does it mean for me?
Physicians have a medico-legal responsibility to follow up on all tests that they personally order (and those ordered under their name by delegates). The College of Physicians and Surgeons of Ontario, the provincial regulatory body under which I work in Canada, states in its Test Results Management policy that physicians must “record that a patient has been informed of any clinically significant result and that appropriate follow-up has occurred.”1 The policy also explicitly states that ED practitioners are to ensure that the system in place allows for the physician who receives the result to be able to follow up appropriately.
So what does this mean? In short, it means that you should keep a log of the tests you order and ensure that you follow up on the results in a time-appropriate manner. When hand-over of care occurs, it also means documenting what test results are pending and who will follow up on them. This also means ensuring that a colleague can update this logbook for you if you are going to be away, by going through either your physical or electronic mailbox. This is obviously quite cumbersome (and still prone to delays and/or errors), which is why a systematic quality assurance process remains the better way.
My ED has a quality assurance process: Am I off the hook?
So let’s say your ED leaders invested time and energy to develop a quality assurance process, because they believed in being proactive rather than waiting for complaints to occur. This is great! But does knowing that colleagues will follow up on your patients’ results absolve you from doing your own due diligence? For two main reasons, it does not.
First, no system is perfect. Despite a well-designed system and well-meaning individuals, some results will eventually go missing. Going back to the well-known Swiss cheese model2 discussed in part one of this blog, adding your own layer of safety for high-risk or vulnerable patients is not a bad idea. You need to balance feasibility with safety, and everyone’s risk tolerance will be different, but you need to find where you are comfortable in the continuum between double-checking everything and doing nothing.
Second, we need feedback. Emergency physicians and trainees historically do not follow up on their patients, especially when the patient is discharged home.3 However, following up on patients’ results (e.g., did the radiologist agree with your read?) and care is one of the most reliable ways to calibrate our clinical judgment—by understanding which of our patients deteriorated and which improved, and whether those outcomes were surprising. If you believe your job is done the minute the patient leaves the ED, you are definitely missing out on great learning opportunities, which could come back to bite you eventually.
I am looking for a new job: Does it really matter if the ED has a quality assurance process?
If you are looking for a new job—whether as a new grad or an old-timer—should you ask about the quality assurance process at your prospective site of employment? Of course you should! As a matter of fact, it may be one of the most important questions you ask when assessing a job opportunity.
The presence or absence of a quality assurance process tells you a lot about the overall risk-management expertise in the ED and about the philosophy of the chief with respect to providing safe patient care. This is likely to spill over into all other decisions made there, from how the department is staffed (e.g., is the focus on physician remuneration or patient safety?) to who your colleagues are likely to be. The quality of the organization and its leadership is reflected in many different ways, and the quality assurance shift is one of them. An ED with a well-functioning quality assurance system must have a collegial group of providers—one that has good citizenship, is ready to take collective ownership of tests ordered by others, and stands together in ensuring safe patient care. That is a department I want to be part of!
What you should be doing when you follow up with patients about their results
Now that you’ve decided where you want to work and how you will personally follow up on patients’ results, what’s next? You need to decide how you will approach your individual responsibility within your ED. Discussing this with colleagues to understand the local culture and systems is important, but what follows are a few important points to remember.
Document and time-stamp every interaction: what result is received and reviewed, what action is taken, and what is the expected outcome. Indicate whom you discussed the case with (or whether a message was left) and what referrals were organized or follow-ups suggested. If you don’t know what to do with an uncommon microbe or a rare diagnostic imaging finding, involve your consultants; they will be enormously helpful in determining the best action to take and may even help with follow-up! Going forward, consider developing local guidelines and agreed-upon practices that will help everyone make the best possible decision. One example of an excellent initiative is the microbiology algorithms developed by my colleagues at the University Health Network in Toronto as part of our Quality Improvement Committee, which you can find here.
In general we are all held to the “reasonable person” standard: What would a reasonable colleague do in this situation? When in doubt, ask a reasonable colleague what they would do. Involve your leadership team in defining accepted standards for things such as where to document quality assurance efforts and what phone number to provide patients who need to call back for results. Also, consider other challenging questions such as the following, for which I have provided my “reasonable person” opinions:
- How many attempts to reach a patient are enough?
This depends on the severity and acuity of the findings. A few attempts by phone with a voicemail message and a letter to the family doctor are enough for a non-urgent incidental finding, such as a pulmonary nodule, but not for a change in acute diagnosis indicating more urgent and time-sensitive management, such as a missed fracture or a missed intracerebral bleed. These more urgent situations might require a call to the police for assistance in finding the patient if they cannot be reached.
- What can and cannot be left on a voice mail message?
For non-urgent concerns, leave a phone number where a health care provider (who has access to the patient’s chart and your note) can be reached. If the problem is more urgent or the voice mail identifies the line as belonging to the patient (not just identifying the phone number or a couple or family) you can be more specific about the need to call a physician urgently, but never give specific health information on a message.
- What can and cannot be shared with next of kin?
Generally, you cannot release information about a patient to family or friends without the express consent of the patient. However, given that most clinicians – myself included – prioritize patient safety above privacy, it’s important to turn one’s mind to the importance of reaching the patient and what, if any, extra information will assist in doing so (e.g., the person’s current awareness of the patient’s situation). Be cautious and err on the side of simply asking them to ask the patient to call you back.
- Is a fax to the family doctor without confirming receipt ever adequate?
Yes, for non-urgent, non-severe findings, but make sure it is clear who is sending the fax and how to reach you in case the family doctor needs to talk to you. But make sure you also attempt to reach the patient to let them know to follow up with their doctor.
- What happens when a critical incident is found as part of the QA process?
Ideally your hospital has a policy to govern these situations. The first priority is always to ensure the patient is now receiving the care they need; after that you should follow your hospital reporting policy and/or call your chief for further advice. It’s never wrong to inform a colleague about additional information regarding one of their patients, but if the outcome was poor or their care may be in question, you may wish to leave this to your chief. Most policies will also cover procedures for reporting near misses as their analysis can help inform quality improvement attempts.
The Bottom Line on EM Quality Assurance and Understanding Individual Responsibilities
Working in the ED is a challenge for many reasons, one being the incompleteness of data when a patient’s disposition is determined. Developing an effective quality assurance process is crucial for both patient and provider safety, as I discussed in part one of this blog. Assessing the presence and type of such a process in your current or a prospective ED is important in determining your own role as a provider—both medico-legally and ethically.
There are countless situations that will challenge you, and many won’t have a perfect answer. I have summarized common concerns above, but stay tuned for an upcoming podcast on Emergency Medicine Cases on which my colleague Dr. Dave Dushenski and I will discuss many other challenging situations. And if you haven’t thought about these situations for yourself, it is time you do—because when they happen, you will be happy it’s not the first time you’re considering these issues!
—Dr. Lucas Chartier is an emergency physician at the University Health Network and North York General Hospital’s emergency departments in Toronto, Ontario. He is the Director of Quality and Innovation at the University Health Network Emergency Department and completed a Master in Public Health at Harvard School of Public Health, with a focus on quality improvement.
- College of Physicians and Surgeons of Ontario. Test Results Management policy. February 2011. Retrieved from http://www.cpso.on.ca/policies-publications/policy/test-results-management. Last accessed September 25, 2016.
- Reason J. Human error: models and management. BMJ. 2000; 320(7237):768-770.
- Dalseg TR, Calder LA, Lee C, Walker J, Frank JR. Outcome feedback within emergency medicine training programs: An opportunity to apply the theory of deliberate practice? CJEM. 2015; 17(4):367-373.