LR3 / Long-term practices and contionous education

Type of Patient Safety Practice
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
“Best fit” category of the reported practice
Education in patient safety/ Human factors
Patient safety theme the SCP/clinical risk management practice is aimed at
Clinical Risk Management focus on long-term practices and continuous education.
Objective of the CRM practice
The objective of the CRM practices concentrates next to the improved quality of care and patient safety also towards saving money. However, it always needs the right implementation approach to succeed [p. 53, 1], such as proactive and reactive approaches within a hospital and [4]. In particular, healthcare professionals need to be integrated into a safe and effective organisational system [p. 164, 2] in order for implementation to achieve its objective.
1. “There is evidence that better coordination of providers’ care can save money and improve quality for patients. But it depends on which way is used to coordinate, and how well the approach is implemented.’”[p. 53, 1]
2. integration of […] nurses into safe and effective organisational systems and processes as part of a hospital’s overall patient safety and CRM programme [p.164, 2]
Short description of the CRM practice, including any references for further information
Clinical Risk Management can be described as where the quality of health care is at stake and most important for the patients safety. CRM tries to interact and control these risks. The major aims were described in article 2 [p. 164, 2]. It’s key elements include risk strategy, identification, analysis, evaluation and treatment [p. 5, 4].
1. Clinical care co-ordination is where two or more providers – individuals or organisations communicate or collaborate with each other and the patient to provide care that takes account of other’s action [p. 6, 1]
2. CRM is described as an approach to improving quality in health care which places special emphasis on identifying circumstances which put patients at risk of harm, and then acting to prevent or control those risks. The aim is to both improve safety and quality of care for patients and to reduce the costs of such risks for health care providers [p. 164, 2]
3. Clinical governance › a whole system cultural change with provides the means of developing organisational the means of developing organisational capacity to deliver sustainable, accountable, patient-focused quality-assured health care [2]
4. Switzerland followed the risk-management standard from Australia/New Zealand [3]
Innovator of the SCP, country of origin
Country of origin:
1. United Kingdom and United States of America both hospitals [1]
2. Australia, State of Victoria hospital[2]
3. Switzerland hospital and service level [3]
Involved health care staff
1. UK: trainee doctors and night nurses; GP and hospital, nurses and other nursing staff [1]
2. US: doctors (between primary care and hospitals); emergency department patients and GP; paediatricians and specialist; [1]
3. Patients: acute hospital care, recently discharged, long-term conditions or with multiple morbidity [1]
4. Graduate nurses from the Nurses Board of Victoria, key stakeholders (staff, who were involved with the […] graduate nurses during their graduate programme [p. 166, 2]
5. Switzerland: CRM practitioners in selected hospitals and at service level [3,4]
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
1. Clinical specialities / sections: Mental health sections; specialist outreach clinics; telemedicine; acute hospitals [1]
2. Disease-management: Asthma, Diabetes, Depression, Heart failure and disease, severe mental illness [1]
3. Australia; hospitals (different units in hospitals [not specified in the text]) [2] and other Victorian health systems [2]
4. Organised mostly by top management facility of the hospital, followed by hospital board [3].
4.1. Different types of hospitals including: somatic, psychiatric and university hospitals as well as rehabilitation clinics.
Summary of evidence for effectiveness, including references
Different articles suggested that in particular for patients with severe or chronic health conditions, costs could be reduced up to 12-53% under the condition of multidisciplinary teams or “discharge planning plus” approaches. Multidisciplinary team approaches can be more enhanced with telephone follow-up. Moreover, case and disease management do not only lead to cost-savings in care comparison plans, also to an improved quality of life [p. 26-29, 1]. The implementation of CRM approaches are categorized as successful in several settings [p. 172, 2 and p. 6, 3] which can be linked to enhanced patient safety.

1. Multidisciplinary team only – cost study “comparing community multidisciplinary teams or community mental health teams with standard care for severe mental illness found total costs that were 12-53% lower for multidisciplinary teams” [p. 26, 1]
2. Discharge planning plus – cost study «A 20% median cost reduction was found in one review of 11 RCT studies of team coordination for stroke patient with early discharge from hospital, with a range of 4-30% cost reduction» [p. 27, 1]
3. Assertive community treatment for mental health patients – cost studies « ACT and case management for server mental illness in a review of 28 ACT and 16 case management studies › all studies in the community were with controls › 5 cost studies, case management had lower total costs when compared to usual treatment” [p. 27, 1]
4. Multidisciplinary teams – costed studies “for heart failure patients, 15 studies found that multidisciplinary teams saved costs” [p. 28, 1]
5. Multidisciplinary team – no cost data “effective intervention included those with telephone follow-up or at home-based component” [p. 29, 1]
6. Case management – cost study “75% of case-managed care plans cost less than the average comparison care plan” [p. 29, 1]
7. Disease management – cost study “effective programs improved quality of life, decreased hospital readmissions by 29-85% and were cost-saving
8. Nurses felt competent after 3 to 4 months concerning the use of patient safety methods [2]
9. CRM seems to be effective [p. 172, 2]

While it does not constitute evidence per se, one article mentions the different challenges of under coordination, problems arising from inadequate handovers and the composition of health care staff [p. 18; 34, 1]. In terms of effective clinical risk management, it can lack due to the missing education in nurses [p. 276, 5]

1. “Under-coordination of medications between providers (failures in accurate transfer of medication information from one provider to another)”
2. “Inadequate handovers […] between primary care providers and specialists […]”
3. “Not providing service coordination and support to patients whose hospitalisation could be prevented by this”
4. “Under-coordination resulting in delay or lack of access to necessary service, resulting in higher emergency […] care costs, especially for poor and vulnerable people, who are less able to find and obtain the preventative or primary care they need” [p. 18, 1]
5. “[…] There is no evidence that extra nurse staffing for patient safety is more effective if that extra staffing time is focused on coordination, or that other methods and systems are more effective” [p.34, 1]
6. “What is required is an improvement in the culture of health care organisations and changing the conditions under which humans work” [p. 276, 5]

Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
There is evidence from one article, that dialogue between different services within one hospital can enable good CRM practices and is transferable to other settings [3]. However, the other articles mentioned point out that the existing models (“showing pathways through which coordination is associated with patient and cost outcome”) lack of implementation and adaptation possibilities into practice [1]. The instrument from Briner et al. could be applied in another setting (Germany) which leads to the conclusion that this model is transferable into other countries than Switzerland and Germany [p. 8, 4].
Summary of available information on feasibility, including references
The concept of Disease-management is very feasible, since it scored a high level of evidence [p.12, 1]. The studies, where disease management was successfully implemented were independent from sponsoring. Moreover, CRM practices can be feasible into everyday practice, when e.g. nurses are intruded to the CRM system from beginning of their employment [2] and the institutionalized dialogue between different stakeholders is ongoing [3].
1. Nurses need pertinent information on CRM at the beginning of their employment and be assisted to translate this information into their everyday practice [2]
2. Institutionalized dialogue to exchange CRM with and between individual services is important for CRM
Existing implementation tools, including references
Existing implementation tools are as followed:
1. Return on Investment Calculator or economic model
2. Cost and saving sharing agent
3. Models of care to prevent hospital admissions
3.1. Disease management [p. 42, 1], case management, multidisciplinary team based approach
4. Chronic care and illness-prevention models
5. Coordination-plus schemes
6. Medication reconciliation [1]
7. Patient risk assessment tools [2], principles of evidence-based practice [2]
8. incidence reporting systems [2, 3], which helps to learn from previous mistakes [p. 2, 4]
Potential for/description of patient involvement in the CRM practice, including references
No specific description of patient involvement was found, since most CRM practices, which were described in the articles focused on the system / health care staff relation [2, 3]. However, for medical reconciliation (MedRec), patients, in particular patients with co-morbidities need to be involved in the practice also to ensure his or her own safety [1].
1. In case of MedRec › proper implemented with high user involvement, savings are likely to cover costs and this will also help develop a quality and safety culture for the patient [p. 40, 1]
2. Particular important for: patients following hospitalisation, with many different specialists involved, with need for long-term care coordination or prevention outside of hospitals; patient group at risk (acute life-threatening illness, chronic, multiple illness)
3. Triangle of health care providers, patients and professionals [1]
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Ovretveit, John (2009): Evidence: Does clinical coordination improve quality and save money? A detailed review of the evidence. London. The Health Foundation.
[2] Johnstone, Megan-Jane (2008): Patient Safety and the Integration of Graduate Nurses into effective organisational clinical risk management systems and processes: an Australian study. Victoria. Q Manage Health Care
[3] Briner, Matthias (2012): Clinical Risk Management in hospitals: strategy, central coordination and dialogue as key enablers. Zurich. Journal of Evaluation in Clinical Practice
[4] Briner et al (2010): Assessing hospitals’ clinical risk management: Development of monitoring instrument. Zurich. BioMed Central Health Service Research
[5] Johnstone et al (2006): Process influencing the development of Graduate Nurse Capabilities in Clinical Risk management: An Australian study. Viktoria. Q Management Health Care, Volume 14, No. 4, pp. 268-278
1. Dr. Jesper Poulsen
2. Ms. Simone Mohrs
Any additional information on the CRM (e.g. implementation barriers and drivers)