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Preventing Contextual Errors Program
Share PrintA “contextual error” occurs when a care plan appears appropriate based on the limited information in the medical record, but is, in fact, inappropriate because it does not address specific life challenges the Veteran is facing that complicate their care. For example, increasing the insulin dose in a patient with uncontrolled diabetes when the underlying problem is that their vision is failing and they can’t read their insulin syringe, or that they have untreated depression and have stopped taking their medications consistently is a contextual error. In the Preventing Contextual Errors (PCE) program, Veterans are invited to carry an encrypted audio recorder into their visit when they check in for their appointment and return it when they leave. The data is uploaded to a secure server and audio-coded by a specialized team in Chicago that also has access to the patient’s medical record. Anonymized reports are sent back to care teams as feedback with examples of contextual errors and appropriately contextualized care. The program has measurably reduced contextual error rates and improved Veteran health care outcomes across multiple VHA ambulatory sites.
Origin:
March 2013, Jesse Brown Department of Veterans Affairs Medical Center (Chicago, Illinois)
Adoptions:
8 successful
Partners:
Diffusion of Excellence, Health Services Research & Development
Recent Updates
Overview
Problem
Solution
Videos
A brief overview of contextualization of care, including a 4-step process to contextualizing care
How to Set Up Preventing Contextual Errors Ql Program
Results
Metrics
- See publication which presents data on over 4000 audio recorded visits. Contextual error rates dropped by 15% over 2 years, and resulted in $25M in preventable hospitalizations. $75 was saved for each $1 invested in the program.
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Images
The blue line shows the percentage of audio recordings collected by patients and audio coded by the team in Chicago in which an identified challenge faced by the Veteran that was impacting their care (e.g. lack of transportation, loss of a caregiver) was addressed during the encounter. The yellow line shows the percentage of audio recordings in which a clue that a Veteran might be facing such a challenge (a “contextual red flag”) was explored (“probed”) by their physician during the visit. From June of 2017 to December of 2018, providers received regular feedback on their performance. Charts such as this one are generated for every participating site for clinical champions to review at each feedback session.
The Preventing Contextual Errors program offers an unusual opportunity for Veterans to play an essential role in helping improve care for other Veterans at their facility. In fact the program would not be possible if Veterans did not see value in volunteering to audio record their visits. Veterans have a high level of commitment to helping other Veterans. The PCE program produced several different kinds of “thank you” stickers, such as this one, given to Veterans when they returned their audio recorders. These stickers also help advertise the program to other Veterans who may not know about it.
Audio recording becomes less threatening when everyone understands that it serves an exclusively educational purpose, and will not be used to single out or rate any provider’s individual performance. Photos such as this one are included in a brochure about the program, illustrating a primary care physician interacting with a Veteran while data is collected via audio for the PCE program. Veterans who volunteer to record their visit are told they can conceal the recorder, carry it out in the open, or turn it off if they change their mind at any point in time. Most put it in their pocket. Surveys of participating physicians and Veterans indicate that few are distracted or bothered by the audio once they understand its purpose.
Videos
An overview of how clinical champions give colleagues feedback using Powerpoint slides we provide, customized for each clinic based on audio coded data, to improve patient care.
Implementation
Timeline
-
2 weeks
Facility clinical leader, e.g. a primary care physician director identifies a clinical champion -
3 weeks
Clinical champion has telephone based coaching session with Chicago program director and reviews all materials in the toolkit, including PowerPoint, implementation plan, examples of feedback, and site promotional materials (poster, pamphlets) -
3 weeks
Clinical champion presents PowerPoint to peer clinicians and any site specific stakeholders, including union representatives if present -
3 weeks
Clinical leader and clinical champion identify approximately GS-7 level staff who will handout and collect audio recorders (“site project coordinator”), and upload to sever when data collection occurs, which varies based on site preferences (e.g. one week every 2 months) -
3 weeks
Chicago based project manager and project coordinator have a coaching call regarding protocol for inviting Veteran participation in waiting areas of clinics, collecting audio, keeping a log, and uploading audio to secure server. -
4 weeks
Audio recording collection begins. -
3 weeks
Clinical champion provides first feedback to peer clinicians
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
|
Files
- These survey results provide data on stakeholder perspective of the program Surveys of Patient and Provider Participants
- The toolkit provides essential documents as templates for establishing the PCE program PCE Toolkit
Links
- This practice is attempting to reduce the prevalence of contextual errors in medical decision making and care planning Preventing Contextual Errors (PCE) Program
Risks and mitigations
| Risk | Mitigation |
|---|---|
| The primary risk to implementation is distrust among providers and staff regarding an audio recording program. | The program must feel safe. A respected clinical champion who is a peer clinician presents the program to colleagues utilizing a PowerPoint that includes details of how data is securely collected and stored using encrypted technology, how it can only be used for its intended purpose, that identifiers are removed before data is shared, how it is legally protected by peer review laws from discovery, and that the only individuals who have access to the audio are the coding team based centrally in Chicago. |
| The second risk to implementation is the perception that it will be an added work-burden to participants. | All data collection occurs while providers are providing usual care, and all feedback occurs during standing meetings at which other performance data is discussed. Any additional effort, which includes occasional brief emailed opportunities to provide written feedback for continuing education or board re-certification credit are optional. |
| The third risk to implementation is skepticism the program will provide value. | At the start of the project the clinical champion shares data that the program does lead to better care for Veterans, with several examples of how it works. In addition, the physicians learn that the program is approved by both the American Board of Internal Medicine and the American Board of Family Medicine for maintenance of certification (MOC) credits. Nurses and pharmacists may also receive continuing education credits. |
Contact
Comment
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Email Contextualizing.Care@va.gov with questions about this innovation.
About
Origin story
Original team
Saul Weiner
Project Director
Gunjan Sharma
Project Manager
Amy Binns-Calvey
Audio-coding Director
Brendan Kelly
Audio-coder
Benjamin Kass
Audio-coder
Rolling out this innovation in SLC...looking forward to seeing how it goes!