STANDARD VIII – CLINIC MANAGEMENT
AND PATIENT CARE POLICIES
Summary
The School has a clinical patient care program that enables it to meet its mission. A coordinated system of clinical governance, administration, management and evaluation exists for both internal and external clinics. A clinic manual is electronically published and distributed to students, faculty, staff and residents. It includes all clinic policies and procedures. Each provider in the clinical program has verified credentials and defined clinical privileges. Each medical record allows for efficient review of the patient’s condition and previous care. The clinical program conducts an ongoing, planned quality assessment, improvement, and compliance program which evaluates the provision of clinical services and provides for remediation when deficiencies are identified. The patient’s bill of rights is published in the clinic manual and posted in the reception area of the clinic. Procedures for receiving and resolving patient complaints, grievances, and appeals are published in the clinic manual. Procedures to address risk management are also published in the clinic manual. Clinical services provided are consistent with accepted health care standards and specific clinical practice guidelines have been adopted by the clinical program.
8.1 The program must have or be assured the use
of a clinical patient care program sufficient to fulfill the mission, goals and
objectives.
Examples of Evidence
·
Description
of institution’s clinical care program
·
Description
of affiliated clinical patient care programs
·
Description
of patient demographics
The clinical patient care program is at the heart of the professional program curriculum. The clinical program provides clinical education, experience and training for students and residents and it serves as a resource for eye care services available to the public. Understanding the close relationship between the volume of patient flow and the quality of clinical education that can be provided, several new initiatives have been undertaken recently in order to grow the patient base. These initiatives include an enhanced media presence, integration of new vision plans, increased participation with existing vision plans, first annual Optical Trunk Show, informational postcards distributed through campus mail, well publicized discounts for UAB employees and students, participation in the UAB Benefits Fair, consistent presence across campus through regular vision screenings in various locations, expanded patient care for pediatric and adult clients of United Cerebral Palsy (UCP) of Greater Birmingham, growth of the Patient Assistance Program (especially the homeless), partnership with Big Oak Ranch to include ongoing patient care for their residents and house parents and establishment of UAB Eye Care as an official clinical site of Children’s Rehabilitation Service in order to increase services to children with special needs. UAB Eye Care, the main clinical facility of the School, had 18,672 patient visits during the 2007-08 fiscal year (October 1, 2007, through September 30, 2008), not including visits to the Optical Service. This represents unprecedented growth of the patient census by 23% in a single year.
Patient care experience for students begins in the fall of the second year. At this point, students conduct screenings through the Community Eye Care Service, assist fourth year students in providing comprehensive eye care through the Primary Eye Care Service, and begin their rotations through the Optical Service. Starting in the summer at the end of the second year, students are independently assigned to the Primary Eye Care Service (i.e., without a mentor from the fourth year), and comprehensive eye care experiences at external clinics are added. In the fall of the third year, rotations through specialty clinical services are initiated, and students continue to provide comprehensive eye care in the Primary Eye Care Service and at external clinics. Presently, half of the fourth year is spent on externships and half is spent in the clinics of the School. Externship sites include a large number of private practices of optometrists or ophthalmologists, co-management/consultation centers, and hospitals (Veterans Affairs, Indian Health Service, etc.). Students are encouraged to choose one site in an institutional/multidisciplinary setting and the other in a private practice or co-management/consultation center. Future plans include the addition of a third externship based on academic performance such that approximately 50% of each class will be provided this opportunity.
UAB Eye Care occupies the entire
ground floor of the
External clinics are operated
primarily through the Community Eye Care Service and provide enhanced diversity
in patient exposure for the students.
They include three Jefferson County Department of Health facilities, UCP
of Greater Birmingham, and Alabama Institute for the Deaf and Blind. These sites offer opportunities for students
to interact with community health care providers and to deliver comprehensive
eye care to low income and special needs patients. Also, patients are seen in five local nursing
homes, and patients are screened at local schools and other facilities in the
Significant time, effort and
money have been expended to upgrade the clinic computer system. In May of 2007, the
Self Study 2008 School Survey Outcomes
Survey question relating to
8.1 (Clinic Facilities):
The mean score is based on the following scale: Strongly Agree = 5, Agree
= 4, Neutral = 3, Disagree = 2, Strongly Disagree = 1, Cannot make a judgment:
not scored. All percentage values were
rounded to the nearest whole number.
|
Survey Questions |
Mean Score |
||
|
The
clinic facilities are (Alumni “were”)
in good condition |
4.76 |
3.99 |
4.44 |
|
Clinic
facilities are (Alumni “were”) well equipped |
4.36 |
4.15 |
4.29 |
|
The
optometry clinic contains (Alumni “contained”) state of the art diagnostic
equipment |
4.29 |
4.10 |
4.35 |
|
There
are an adequate number of clinic conference rooms |
4.26 |
3.95 |
3.96 |
The above survey questions were also included in the Standard VII Report. In the 2008 survey of the School’s faculty, students, and alumni, among all respondents who could judge, 86% (283/329) strongly agreed or agreed that clinic facilities were in good condition, 88% (276/313) that clinic facilities were well equipped, 87% (262/301) that they contained state of the art diagnostic equipment, and 83% (252/305) strongly agreed or agreed that there were an adequate number of clinic conference rooms.
8.2 A coordinated system of clinical governance,
administration, management and evaluation must be in place for clinics managed
by the program.
Examples of Evidence
·
Clinic
administration organization chart
·
Description
of clinic administration
·
Clinic
management policies
·
Procedures
for evaluating clinic administration
·
Procedure
for evaluating effectiveness of clinical operation
·
Position
description(s) for principal administrators of clinical programs
Clinic Governance
A comprehensive description of clinic governance, including administration and organizational charts, policies, procedures and position descriptions, is available in the clinic manual (Clinical Policies and Procedures for Everyone, Clinical Policies and Procedures for Faculty, Interns and Residents, Clinic Staff Policies and Procedures).
Clinic Administration
The Chief of Staff is ultimately responsible for all aspects of the clinical program. The Director of Clinical Programs and the Practice Manager report to the Chief of Staff. The clinical program is divided into six clinical services: Primary Eye Care Service, Community Eye Care Service, Cornea and Contact Lens Service, Pediatric Optometry Service, Ocular Disease and Low Vision Service, and Optical Service. A Service Director is responsible for the administrative oversight of each of these clinical services. The Service Directors report to the Director of Clinical Programs. Additionally, some subspecialties have a designated Service Chief who serves under the direction of his or her Service Director.
Three residents provide care within the clinics of the School. The Resident in Family Practice Optometry provides care primarily within the Primary Eye Care Service, the Resident in Cornea and Contact Lenses provides care primarily within the Cornea and Contact Lens Service, and the Resident in Pediatric Optometry provides care primarily within the Pediatric Optometry Service. Each resident reports to his or her Residency Supervisor, who serves as a mentor for the year. The Residency Supervisors report to the Director of Residency Programs, who in turn reports to the Director of Clinical Programs.
The Director of Clinical Programs is responsible for overseeing the direct daily activities of the clinic enterprise and chairs the Clinic Council. This council comprises the Service Directors, Director of Residency Programs, Chair of the Department of Optometry, and Chief of Staff. The Clinic Council is the main advisory body to clinic administration although final responsibility resides with the Chief of Staff. The Clinic Council meets monthly to discuss existing policies and to consider new policies that would affect operations of the clinical program.
The Practice Manager supervises clinic staff and evaluates the effectiveness of clinic operations, including financial measures and patient census. Each month, the Practice Manager prepares a report for Clinic Council. In this report, several key factors are calculated. These factors include kept patient appointments, income, itemized expenses, and profit or loss. These factors are reported for each clinical service and for the clinic as a whole. Comparisons are made between a month in the current fiscal year and the same month in the previous fiscal year. Comparisons are also made between current fiscal year to date totals and previous fiscal year to date totals. Several other reports are generated in the clinic practice management system and reviewed. These reports reflect financial indicators of “best practices” and include outstanding insurance claims (as a group and by carrier) by dollars and by days as well as outstanding accounts receivable (patient balances) by dollars and by days. All denied claims are reviewed on an ongoing basis and trends, if any, are identified and communicated to the appropriate providers.
Clinic Evaluation
Clinic administrators, including the Chief of Staff, Director of Clinical Programs, and Practice Manager, are evaluated according to the standard policies and procedures of the University and the School. Formal, written evaluations are performed on an annual basis. The Chief of Staff is evaluated by the Dean. The Director of Clinical Programs is evaluated by the Chief of Staff. Other clinical faculty members are evaluated by the Optometry Faculty Advisory Committee and the Chair of the Department of Optometry. Each staff member is evaluated by his or her direct supervisor, and the Practice Manager’s direct supervisor is the Chief of Staff.
8.2.1 A
clinic manual which includes all clinic policies and procedures must be
published and accessible to student clinicians, faculty and staff.
Examples of Evidence
·
Clinic
manual
·
Electronic
clinic manual
A clinic manual, including all clinic policies and procedures, is updated and published annually. This clinic manual is divided into three parts. The first part contains information for faculty, staff, students, and residents (i.e., everyone) (Clinical Policies and Procedures for Everyone). The second part contains information specifically for faculty, students, and residents (Clinical Policies and Procedures for Faculty, Interns and Residents). The third part contains information specifically for clinic staff (Clinic Staff Policies and Procedures). Orientation to the clinical program is held during the second and third professional years, and the clinic manual is reviewed at this time.
Hard copies of the clinic manual were distributed through the year 2000. Since 2001, the clinic manual has been published electronically. It is available to all faculty, staff, students, and residents via the intranet site http://iweb.opt.uab.edu/clinicmanual. For security purposes, this intranet site is available only from campus computers. The clinic manual may be downloaded or printed for personal use. Before entering the clinic, all second year students are required to sign a clinic manual verification form indicating that they have read and understand the clinic manual as well as a confidentiality agreement form. Both of these forms may be printed from the intranet site.
8.2.2 The
program must verify credentials of faculty members who serve in the clinic.
Examples of Evidence
·
Faculty
credentials
·
Credentialing
process
Faculty and residents must present credentials to clinic administration in order to be granted patient care privileges. Required credentials include licensure, advanced training and education, certification in cardiopulmonary resuscitation, and immune testing and vaccination records. These credentials are maintained in secure files. The Chief of Staff reviews each credentials file on initial appointment and annually thereafter and issues a letter of clinical privileges based on the credentials presented.
8.2.3 The
program must define the scope and extent of clinical privileges for each
faculty member who serves in the clinic.
Examples of Evidence
·
Description
of procedures to grant clinical privileges
·
Completed
privileging documents (on-site)
Based on the credentials presented, the Chief of Staff issues a letter of clinical privileges (Letter of Credentialed Clinical Privileges: UAB Optometry Clinical Services) to each faculty member and resident on an annual basis. Providers without all of the necessary documentation on file are notified by telephone and written memorandum and are given two weeks to provide a copy of the missing documents. Individuals who fail to provide the necessary documents within this time period are ineligible for all clinical duties, and written notification is sent to their supervisor(s) and to the Dean.
8.2.4 The
patient record must allow for efficient review of the patient’s condition and
any previous care that has been provided at the program’s clinical facility.
Examples of Evidence
·
Copies
of written or electronic patient records (on-site)
A medical record is maintained for each patient of the clinical program. This record provides for efficient review and is accessible both electronically and in hard copy. Standard forms have been adopted in all clinical services and imported into Compulink to make reporting more uniform and easier to follow from year to year. In cases where a form is not appropriate, a blank, lined progress note is used.
Each patient is assigned a unique medical record number (MRN). This number identifies the medical record electronically and on the hard copy. Hard copies are maintained in numeric order by a full-time staff in a secure file room. Retrieval of a record requires that the MRN be obtained through Compulink. Once the MRN is obtained, the record can be quickly accessed electronically or in hard copy. For security reasons, hard copy records may not be removed from the clinic floor, and electronic records are available only from computers with access to the Compulink server.
8.2.5 The
clinic must conduct an ongoing, planned quality assessment, improvement and
compliance program, which evaluates the provision of health, eye and vision
services and provides for remediation when deficiencies are identified.
Examples of Evidence
·
Description
of quality assessment program
·
Evaluation
of clinic services by staff, patients or students
·
Examples
of remediation of deficiencies
·
Description
of faculty/staff/student in-service programs
The assessment and improvement of quality and compliance are integral parts of clinical care. The quality assurance program and compliance plan are documented in the clinic manual (Clinical Policies and Procedures for Everyone, pages 13 and 25-35).
Self Study 2008 School Survey Outcomes
Survey question relating to
8.2.5 (Clinical Standards of Care):
The mean score is based on the following scale: Strongly Agree = 5, Agree
= 4, Neutral = 3, Disagree = 2, Strongly Disagree = 1, Cannot make a judgment:
not scored. All percentage values were
rounded to the nearest whole number.
|
Survey Questions |
Mean Score |
|
|
Patient
care provided by the school is of high quality |
4.54 |
4.22 |
|
Patient
care provided by the School of Optometry exceeds the standards of care |
4.38 |
4.21 |
In the 2008 survey of the School’s faculty, staff, students, and alumni, among all respondents who could judge, 95% (295/309) strongly agreed or agreed that patient care provided by the School is of high quality, and 91% (281/308) strongly agreed or agreed that patient care provided by the School exceeds standards of care.
Dr.
The patient’s experience, from the patient’s perspective, is a valuable tool in managing quality. At registration, a Patient Survey (UAB Eye Care Patient Survey) is given to each new patient and to each established patient who has not been seen in at least six months. Of the last 5,204 responses to the quality measures in the survey (numbers 2 through 12), 99% (5,162) were positive and only 1% (42) were negative. In addition to routine analysis of survey responses, any notation of deficiency or excellence is shared with the appropriate Service Director. Approximately once a month, a “secret shopper” is solicited. The Secret Shopper Questionnaire obtains more detailed information on perceptions of services and facilities. In some clinical services (e.g., Optical Service), telephone interviews are conducted several weeks after a patient is seen. These follow-up calls are important for quality monitoring.
The student’s experience, from the student’s perspective, is also a valuable tool in managing quality. As described in Standard II, students complete written evaluations of all instructors and courses, clinical as well as didactic. Student evaluation reports are reviewed by the instructor, the coursemaster (in the case of a clinical course, the Service Director), and the Curriculum Committee, which includes the Director of Clinical Programs. Students’ opinions, as demonstrated in summary student evaluation reports for all clinical courses (Course Evaluation Report of Clinical Course) and for all clinical instructors (Course Instructor Evaluation Report of Clinical Course) over the academic year from the fall of 2007 through the summer of 2008, reflect a strong institutional commitment to quality.
In addition to the formal quality assurance program and compliance plan documented in the clinic manual, it is crucial to continually foster an atmosphere of patient-centered care among faculty, staff, students, and residents. This is accomplished, in part, through regular student and resident orientations, quarterly clinic staff meetings, quarterly clinical service faculty meetings, monthly Clinic Council meetings, and quarterly departmental faculty meetings. Professional development courses, such as “Creating a Culture of Exceptional Customer Service,” are offered by UAB Training and Development, and they emphasize the importance of keeping the patient’s welfare a priority. Also, all providers receive documented training in compliance and in HIPAA policy.
8.2.6 The
clinic must publish or post policies and procedures on the patient’s rights and
responsibilities.
Examples of Evidence
·
Posted
patient bill of rights
·
Handouts
which include patient bill of rights
·
Publication
which include patient bill of rights
·
Informed
consent document
The clinical program has adopted a Patient’s Bill of Rights. It is displayed in the reception area and is published in the clinic manual. A General Informed Consent is sought from each patient at registration. Specific informed consent for individual procedures, such as punctal plug insertion or corneal foreign body removal, is available through Compulink when indicated. All patients receive a Notice of Health Information Practices, and an Authorization for Use or Disclosure of Information is signed when needed. The Advance Beneficiary Notice of Noncoverage is used for Medicare patients when applicable.
8.2.7 The
clinic must have written procedures for receiving and resolving patient
complaints, grievances and appeals.
Examples of Evidence
·
Documents
with relevant policies
·
Files
of complaint, grievances and appeals (on-site)
·
Clinic
manual
The clinic manual documents the procedures for receiving and resolving patient complaints, grievances, and appeals (Clinical Policies and Procedures for Everyone, page 12). Patients have several avenues by which they can express complaints, grievances and appeals. These avenues include the patient survey, written letter and personal discussion with an administrator, faculty, staff, student or resident. Any administrator, faculty, staff, student or resident who receives a patient complaint, grievance or appeal should resolve the issue immediately. In some cases, resolution can be accomplished without involving anyone else. When that is not possible, the administrator, faculty, staff, student or resident should follow the organizational structure in reporting the issue and obtaining assistance. Any significant incidents should be documented in writing, including their resolution, with a copy to the file in clinic administration. In order to simplify the process of documenting issues which are handled verbally, a three-part Patient Action/Comment Report has been developed and is available throughout the clinic.
Most complaints, grievances, and appeals are handled by the Service Director of the clinical service in which they originate. On rare occasions, Clinic Council’s involvement and/or University resources may be required to obtain resolution. Appeals follow the organizational structure as described in 8.2, with the Chief of Staff as the final authority on patient issues.
8.2.8 Clinic
programs must have established procedures to address risk management such as
liability, security and safety.
Examples of Evidence
·
Liability
policies including professional liability
·
Security
policies
·
Safety
policies
·
Emergency
procedures
·
Infection
control policies
The clinic manual includes procedures to address risk management (Clinical Policies and Procedures for Everyone, pages 17-23). All areas are covered, including security, safety, medical emergency, fire, severe weather, power failure, evacuation plans, and infection control. All credentialed providers are required to have Professional Liability Coverage. The University is self-insured, and this liability protection provides each individual with $1,000,000 per occurrence and $3,000,000 annual aggregate coverage. General Liability Coverage is also provided by the University. It covers $1,000,000 per claim with no aggregate limitation.
8.3 Eye and vision care services provided must
be consistent with accepted and well-established health care standards such as
clinical practice guidelines.
Examples of Evidence
·
Adopted
clinical practices guidelines
·
Description
of access to clinical practice guidelines
·
Quality
assurance program
As documented in the clinic manual, the clinical program has adopted the Optometric Clinical Practice Guidelines of the American Optometric Association (Clinical Policies and Procedures for Faculty, Interns and Residents, page 10). These are available in hard copy in each clinical service and electronically at http://www.aoa.org/x4813.xml. The quality assurance program is described in 8.2.5.
Standard VIII: List
of Hyperlinked Documents and Pages
|
Document/Page |
Hyperlink |
Reference in Report |
|
Clinical Policies and Procedures for Everyone |
8.2, 8.2.5, 8.2.7, 8.2.8 |
|
|
Clinical Policies and Procedures for Faculty, Interns and
Residents |
Clinical
Policies and Procedures for Faculty, Interns and Residents |
8.2, 8.3 |
|
Clinic Staff Policies and Procedures |
8.2 |
|
|
Clinic Manual |
http://iweb.opt.uab.edu/clinicmanual
(not available externally) |
8.2.1 |
|
Letter of Credentialed Clinical Privileges |
Letter
of Credentialed Clinical Privileges: UAB Optometry Clinical Services |
8.2.3 |
|
UAB Eye Care Patient Survey |
8.2.5 |
|
|
Secret Shopper Questionnaire |
8.2.5 |
|
|
Course Evaluation Report of Clinical Course |
8.2.5 |
|
|
Course Instructor Evaluation Report of Clinical Course |
8.2.5 |
|
|
Patient’s Bill of Rights |
8.2.6 |
|
|
General Informed Consent |
8.2.6 |
|
|
Notice of Health Information Practices |
8.2.6 |
|
|
Authorization for Use or Disclosure of Information |
8.2.6 |
|
|
Advance Beneficiary Notice of Noncoverage |
8.2.6 |
|
|
Patient Action/Comment Report |
8.2.7 |
|
|
Professional Liability Coverage |
8.2.8 |
|
|
General Liability Coverage |
8.2.8 |
|
|
Optometric Clinical Practice Guidelines of the American Optometric Association |
8.3 |
|
|
2008 Self Study Survey Data |
8.1, 8.2 |
|
|
2008 Self Study Alumni Survey Data Grouped by Graduation Year |
2008 Self Study Alumni Survey Data Grouped by Graduation Year |
8.1, 8.2 |