Agency Policy Paper
Ryan W Jarman
Grand Canyon University

Agency Policy Paper
Hunter Carlson is the senior risk manager at University of Colorado Memorial Hospital, his duties include investigation of Notices of Claim, lawsuits and licensing board complaints or other threats of legal or regulatory action. Hunter is also responsible for analyzing clinical care, collaborating with medical staff and other members of the health care team to complete the necessary investigation of events and legal cases. It is his job to recommend steps for action to mitigate legal exposure to the University. In addition he is responsible for communication with the health care team, patients, and their families, University leadership and legal counsel. In Hunter’s position he is responsible for the development of educational presentations on legal concepts related to specific clinical areas; review of patient occurrences and convening root cause analysis when applicable.

Memorial Hospital has committed to contribute to positive health outcomes for patients. Examples include whether or not aspirin was given to heart attack patients or whether patients were counseled to quit smoking.

• Outcome measures refer to the effects that care had on patients, for example, whether or not a patient's diabetes is under control based on laboratory tests. Use of outcome measures is particularly controversial in pay-for-performance because outcomes are often affected by social and clinical factors unrelated to the treatment provided and beyond the provider's control. For example, providers may follow practice guidelines regarding monitoring blood sugar levels and counseling diabetic patients regarding their diet, but ultimately, the patients' eating and exercise behaviors will determine control of their diabetes. Increasingly, outcome measures also include cost savings.

• Patient experience measures assess patients' perception of the quality of care they have received and their satisfaction with the care experience. In the inpatient setting, examples include how patients perceived the quality of communication with their doctors and nurses and whether their rooms were clean and quiet.

• Structure measures relate to the facilities, personnel, and equipment used in treatment. For example, many pay-for-performance programs offer incentives to providers to adopt health information technology.
Throughout the University of Colorado health system a strong commitment has been made to reduce medical errors. In the Respiratory Therapy Department we are focusing specifically on wrong patient errors. Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-fold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier. ("NPSG," 2015)

As a respiratory therapist I am expected to perform procedures under physician direction in all patient areas. I do patient assessments, care plans, plan implementation and evaluation and