OSHA-7/25 Community health Addresses the public health (well being) of a community of people Health characteristics to be improved or services

es to be provided are identified Consumer oriented health education and information Public health sometimes viewed as government-sponsored healthcare Health information and education and communication Reduces the risk, promotes better health Empowers the community to identify their needs o Epidemiology: infection/illness o Environmental: workplace hazards, seasonal hazards (lawnmower, fireworks, barefoot/improper shoegear) Health promotion: DM Community Community = a group of people with common interests or who share a distinct segment of society o Medical professional community Community health Practice sites you may deliver care in within the community Buzz words for the practicing physician as part of a community of health care providers 1) Practice sites Community centers Nursing homes Home care/Pt home Screening sites e.g. Broad Street run, public events Homeless shelters/Prisons Multi-physician office practice Clinic settings Providing care: o You know what to do, but how do you find out the rules and regulations of the practice site? Policy and procedure manual Protocols for specific cases Standards of care Need to know facilitys philosophy on the possession of and handling of certain items such as: o Medications Is the facility going to order the medication you are going to use? May have to request in certain medications; need to have policies and procedures for all medications o Sharps o Instruments **Who provides supplies and orders them?? If you bring your own instruments, how are you going to clean them, etc? Scope of serves you are to provide Where you are to document those services Infection control practices, including procedures to follow if no H2O is available, no red bag trash, no sharps containers, needle-stick at site OSHA guidelines: remember wear gloves and handwashing/gel use! Decontamination of equipment or re-use of equipment o Using a BP cuff, or a wheelchair, make sure you clean these items in between patients o There are plenty of items you use on a day-to-day basis that you do not think about cleaning that need to be cleaned Transportation of hazardous/biohazardous materials (trash, phenol, specimens, and cultures) o If you are transporting something, make sure you have them in some sort of storage, have identification on each of the specimens and a log just in case something happens during transport

Procedures to follow when the site of practice is not clean (home care) o Use newspapers, bleach, hand sanitizers How/where to document care o Not all homes are clean, not everyone is capable of cleaning their home. Bring in newspaper, so that when you put down your bag of instruments/etc, you put it on the newspaper and you know exactly what you are putting your bag down on instead of the dirty floor o Make sure nothing crawls into your bag or instruments since many homes are infested with bugs/etc o If you are doing a dressing change or something, you must dispose of the hazardous material; you could take the saturated dressings and put it in a bag with some bleach and swish it around for a little bit and then throw it away in the normal trash o Make sure you can write down some notes, on what you did, what supplies you used, etc. So you can document it in the patients chart when you get back to the office Tips o Calibration, maintenance and cleaning of equipment used at various sites that you bring/transport may have to be performed Dont want to get abnormal testing results because the machine got jiggled during transport So, when you get to your destination, make sure to recalibrate your machines Wear appropriate dress/garb for the situation, including PPE

Scope of practice issues o Know scope of practice as ID in the Podiatric Practice Act in the states in which you are practicing Every state has a different rule, some only let you work up to the ankle, some states allow you to work up to the knee, need to know your scope of practice o Know when to refer a pt to another or different healthcare provider There are times when you have done everything you can for a patient and you are still not getting the results you want, that is the time when you refer a patient to someone else Common Sense Issues o Remember to remove your gloves when finished and wash your hands/gel if no water o o Have adequate office supplies with you Bring your business cards & some means of tracking patients that you see (referral slips) for marketing or follow up care

If equipment is provided for you: o Inspect materials for signs of contamination, including expiration dates on meds and biologicals o Remember event-related vs date-related o Remember gluteraldehyde can be used to decontaminate as well as sterilize it is the time the instrument soaks that is the difference (cold sterilization) 2 types of gluteraldehyde: daily use and 28 days gluteraldehyde Decontamination: Gluteraldehyde 2% for about 10-20 minutes depending on manufacturer Sterilization: **Autoclave steam under pressure Cold sterilization soaks for 20 hrs in 2% gluteraldehyde to achieve sterility As a provider of care, you may be asked: o To participate on facility committees, such as Quality (QA), Peer, Privacy, Safety and Security, Ethics, Credentials o To participate in research or other data gathering initiatives

Sometimes there are mandated reporting of data Gunshot wounds, animal bites, abuse, infections

Privacy and Security HIPAA Privacy Rules: May need authorization to copy notes Confidentiality extends into the elevators and dining rooms or cafeteria Shred scrap notes when documented; watch what you do with notes you make and take that

have patient information on them You may be asked to sign a confidentiality agreement or business associate agreement Billing: Privacy/security of HIPAA is rolled into a billing compliance program because that is where the sanctions are found o Computer screens not visible to public o Social security number access and use o Patient ID/ID theft o Insurance fraud-billing fraud

Patient safety

Starts with a Culture of Safety philosophy Issues that need to be reported to an institutions Patient Safety Committee, or even reporting to DOH or other entity Serious events (PSA- Patient Safety Authority and DOH-Dept of Health) o Situation involving the clinical care of a patient that results in death or compromises safety and results in unanticipated injury requiring additional health care services o Does not include an Incident

Incidents (PSA) o Situation involving the clinical care of a patient which could have injured the patient but did not cause an unanticipated injury or require additional health care services Infrastructure Failure (DOH) o Undesirable or unintended situation involving the physical plant or service delivery systems of a facility, or o Interruption or discontinuation of a service which could seriously compromise patient safety

Falls, infections, injury Sometimes there are mandated reporting of data o Gunshot wounds, animal bites, abuse, infections

MCARE: Medical Care Availability and Reduction of Error Act PA PSRS o Mandatory, confidential, statewide information system for reporting events, occurrences or situations that have, or could have (near misses) resulted in unanticipated injury to the patient in a covered facility
Hospital, ASC, Birthing Center, Behavioral Health Center

Event types o Medication error Dose, wrong medicine, time of taken, allergic to medication o Adverse drug reaction not related to error o Equipment/Supplies/Devices (SMDA) If equipment breaks during use o Do not throw device away must be sequestered! o Falls o Communication failure o o o o o

SBAR method: Situation, Background, Assessment, Recommendation Error related to procedure/test/Tx/surgery Complication of procedure/test/Tx (even if predicted) Transfusion errors or reactions Skin integrity/infection Preventable incident; when someone comes in with skin intact and leaves facility with a bed sore etc. ER services/response

o o o o o

Physical plant/utilities/service disruption Administration/management If there was a strike outside the building and it interrupted our services Medication safety Criminal illegal activity Theft of our supplies such as our instruments, guns, knives, etc Disclosure procedure Tell patient what happened, and what we are going to about Follow up letter to patient/family Other/misc: Leaving charts unattended on desks Misfiling reports in wrong chart pt requests records and gets another pts info Prescriptions with wrong pts name Prescription pads left unattended, or copies left unattended Theft of prescription pads should be reported to DEA

MCARE requirements when serious event occurs o Disclosure procedure: honest disclosure to pt/family Follow institutional policy o Follow up letter to pt/family o MCARE-mandated continuing education in pt safety for doctors for license renewal Evaluating quality o Quality Assessment and Performance Improvement a multi-disciplinary review of customer needs, process eval, quality exceptions, regulatory and accreditation standards as well as reports of near misses o Evidence of quality and pt safety go hand-in-hand o Insurance carriers and accreditation agencies always ask how you evidence quality care

2) Buzz words HIPAA-Privacy notices-confidentiality and security of patient information (**will be on the exam for sure**) o Have to make sure your office is locked, that charts arent just laying around, etc

MCARE (Medical Care Availability and Reduction of Error-PA, Act 13) insures care is available and high quality in state of PA Culture of safety organizational philosophy Disparity of Healthcare (underserved populations, access to care) HEDIS standardized performance measures used for managed care insurances o May be diabetic HEDIS measures, otherwise podiatrists do not participate in HEDIS measures P4P (Pay for Performance) full pay when indicators are met, benchmarks are followed, never events, meaningful use; you perform you get paid o An infection is considered a never event ORYX standardized measures for delivery of care across diff types of service sites (hospitals, outpatient, office), may see voluntary reporting indicators National patient Safety Goals (JACO) o Standardize measures, set benchmarking (internally, externally) o Prevent/reduce injury o Adherence to national standards/best practices supports quality care Peer Review, Self reporting of events- physicians reviewing other physicians; charts reviewed by physicians in similar types of practice; if you make a mistake, amputate the wrong toe etc., make sure to report it FMEA (Failure Mode and Effects Analysis) looks at potential causes, preventative RCA (Root Cause Analysis) after event; after the event has already occurred, look at all the contributory factorsidentification issues, communication issues, etc NEED TO KNOW THE DIFFERENCE B/W FMEA AND RCA SBAR (Situation-Background-Assessment-Recommendation) technique that provides a framework for communication b/w members of the health care team about a pts condition o An easy-to-remember, concrete mechanism useful for framing any conversation

Way of scripting a conversation, so the nurse/doctor gets the appropriate information to treat the patient

Benchmarking (***will be on the exam for sure**) an improvement tool whereby a company measures its performance or process against other companies' best practices, determines how those companies achieved their performance levels, and uses the information to improve its own performance. Evidenced based practice the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. QA

o Quality Assessment and Performance Improvement, Quality Assurance

A multi-disciplinary review of customer needs, process evaluation, quality exceptions, regulatory and accreditation standards, as well as reports of near misses o o Changes focus on outcome driven care and places a major emphasis on data collection and analysis to drive care planning and to improve quality

o o o

Quality Control Best Practices Everyone is looking for the best practice to emulate, because that is what the patient is paying for; the best care PI = Performance Improvement TQM = Total Quality Management Zero Defect

P-D-C-A o Plan, Do, Check, Act: one of the most commonly used paradigms for QA o o

Also called the Shewhart Cycle Made popular by W. Edward Deming Based on the Scientific Method Alternate version: P-D-S (study)-A

Six sigma Set of practices designed by Motorola to improve processes by eliminating defects Used in the air industry; pilots have a checklist before they can start the planes engine; way to prevent errors 6-sigma = the ability of highly capable processes to produce results at 6 standard deviations of the normal distribution, or about 3.4 defects per million DMAIC: Define, Measure, Analyze, Improve, Control HRO (High Reliability Organization) one that has fewer than normal error rate (defects) Decrease in error due to culture changes in the administration o Culture of Safety o If you do not have that support, then you will never have a HRO o Empowers anyone to halt the process to keep the patient safe, if something is wrong-STOP Empowering the front line to halt procedure if something is wrong NCQA (National Committee on Quality Assurance) Private, not for profit company dedicated to improving healthcare quality Quality Reporting CMS has enacted quality reporting of certain indicators o Reduction of reimbursement for no reporting o Podiatric measures could be: % of patients with DM who have fingerstick at routine visit Peer review Committee of peers who evaluate care provided o Looking at the standard of care, system issues or documentation issues o Issues in these areas are of concern when litigating a case or evidencing quality care Self-reporting of issues, legal notices, serious events, poor outcomes are triggers

Credentials committee Evals the credentials of an applicant Credentialing activities are seriously reviewed during cases of litigation of med mal o Includes original source verification of education, certification, licensure, insurance, etc o Credentialing refers to the knowledge base, privileging refers to granting of privileges to perform a certain activity based on credentials Ethics Bioethics: moral/ethical principals on modern human life issues o Termination of care, Do Not Resuscitate, Court-ordered care (Jehovas Witness/blood) o Impaired care provider o Incapacitated provider o Harassment/hostile work environment Refer to Ethics Committee/Ombudsman