|Year : 2013 | Volume
| Issue : 1 | Page : 7-10
Evaluation of insured errors in the referral system of villages and towns populated under twenty thousand in Isfahan, using the failure mode and effects analysis model
Elnaz Kalantari1, Syed Masoud Shajari Pour2, Noora Rafiee3
1 M. S. Students of Health Care Management, Tehran University of Medical Science, School of Public Health, Tehran, Iran
2 Yazd University of Medical Science, Yazd, Iran
3 Expert of Isfahan Medical Services Insurance Organization, Isfahan, Iran
|Date of Web Publication||30-Nov-2013|
Tehran University of Medical Science, Isfafan
Source of Support: Health Management and Economic Research Center of Isfahan University of Medical Sciences, Conflict of Interest: None
Introduction: The best strategy for implementing rural insurance program in the form of referral system is "Family Physician". Since, there were both background and culture of referral system in the villages, the researchers decided to implement the mentioned program at first in the villages. This study intends to evaluate the insured errors through Failure Mode and Effects Analysis (FMEA) model. Materials and Methods: The present research is applied one, the study type is cross-sectional, and it is an action research (using Delphi technique, nominal group, and brainstorming). The population of the study consisted of the experts in the villages and towns populated under 20,000 employed at Isfahan Medical Services Insurance Organization and also experts of Health Centers in the province and number one townships. Sample size and sampling methods were 17 selective accessible in time and place. The research data was collected through a worksheet which was made according to the identified errors. The validity of FMEA worksheet has been confirmed by the experts and its reliability has been approved because of its wide use by many researchers in the field of health in other countries. The research data was collected through observations, literature review, focus group discussion, and brainstorming for the purpose of scoring the potentials of insured errors in the process of referral system during last year. Findings: The findings of the study revealed that the highest and the lowest risk priority number in order counted for "receiving the services from a noncontracted paraclinic" (25.7%) and "visiting a family physician who does not support the area" (13.94%). Conclusion: As the results indicate, most errors in the referral system are related to the patient (the insured person) and the high percentage of his visits to a higher level healthcare system. So, family physician is to suggest a higher level of health system only in necessity, because in the case of visiting the second and third levels directly, many resources will be wasted.
Keywords: Failure mode and effects analysis, insured person errors, referral system
|How to cite this article:|
Kalantari E, Pour SM, Rafiee N. Evaluation of insured errors in the referral system of villages and towns populated under twenty thousand in Isfahan, using the failure mode and effects analysis model. Int J Health Syst Disaster Manage 2013;1:7-10
|How to cite this URL:|
Kalantari E, Pour SM, Rafiee N. Evaluation of insured errors in the referral system of villages and towns populated under twenty thousand in Isfahan, using the failure mode and effects analysis model. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2019 May 26];1:7-10. Available from: http://www.ijhsdm.org/text.asp?2013/1/1/7/122416
| Introduction|| |
The best strategy to implement rural insurance program in the form of referral system is "Family Physician". Since the referral system is the basis of organizing health, and there are background and culture of referral system in villages, the decision was made to implement the program first in the villages. The plan for organizing and promoting rural health insurance and issuing health care insurance notebook for them and implementing family physician program were done to establish the referral system in country and preventing people from referring to various physicians.  This program, as an important health program, is now imparting the benefits to almost all the residents of villages and towns populated under 20,000 through the same conditions and easy accessibility to health services. However, the main difficulties of an insured person in this field are: The desire for a false referral by the insured person, lack of awareness of insured people in villages and towns populated under 20,000 in using health care insurance notebook; and the wrong belief that specialists work better than the general practitioners and so on.  Colman also states in his studies that 55% of patients referring to medical emergency units having urgent problems could have been recovered by receiving a general practitioner's advice or care instead.  Therefore, it is crucial to recognize the activities inflicting damages on system or threatening the permanence of the program. The analysis of a futurologist has been regarded as a more positive approach to solve the problems as it focuses on their knowledge and skill instead of giving prominence to the weaknesses. 
Failure Mode and Effects Analysis (FMEA) is one of the qualitative methods for analyzing the risks and also a means to evaluate the futurologist's risk that has been extensively used in automotive industries and aerospace. It has been used in the field of medical cares since early 1990 decades and has been confirmed by a number of safety agents such as a common commission, an Improving Health Institute (IHI), and an Institute for Secure Methods of using Pharmaceuticals (ISMP).  In several studies, researchers have proved that FMEA model has been effective in reducing the risks after doing necessary interventions for a patient.  Linkin et al., in an article titled "Using HFMEA to evaluate system errors in the process of sterilization and using surgery instruments" have concluded that a few positive biological tests produced by infection transfusion were due to nonsterile surgical instruments. They also recognized several system errors that were not apparent before the study.  The study intends to evaluate the insured errors with the assistance of FMEA for recognizing the probable difficulties to implement the program.
| Materials and Methods|| |
The present research is applied one, the study type is cross-sectional, and it is an action research (using Delphi technique, nominal groups, and brainstorming). The population of the study was experts in the villages and towns populated under 20,000 employed at Isfahan Medical Services Insurance Organization and also experts from health centers in the province and number one townships. The study standards were experts on health affairs in villages and towns populated under 20,000 having at least 1 year of related work experience in Isfahan Department General of Health Services Insurance or in Public Health Center either in Isfahan or in a number one township accessible in time and place. Sample size and sampling method were 17 available selectives. Abundance rate is 17.5% in department general, 65% in public health and number one township, and 17.5% of family physicians.
Before starting with 10 steps of FMEA model  in a meeting with a group of experts, we took the opportunity of being face-to-face to instruct them the necessities about FMEA model and the aim of this research was presented to them. In the first step (reviewing the proccess), referral system in villages and towns populated under 20,000 was selected in order to manage and organize the system better, considering the insured errors in the referral system, and the results obtained. In the second and third steps (brainstorming for the potentials of errors and writing the potential effects of each error state), the main present errors of an insured person in referral system and the plan of rural insurance were distinguished in a meeting with experts from Medical Services Insurance Organization by drawing the process of the current referral system, using group techniques, and brainstorming. We also discussed the effects of errors and the methods of controlling them in the fourth, fifth, sixth, seventh, and eighth steps (determining the intensity degrees, occurrence and diagnosis, calculating risk priority number (RPN) for each error state, and priority of error state) a verified worksheet was drawn corresponding to the recognized errors. (Validity of FMEA worksheet was confirmed by the experts and the reliability has also been confirmed because it has already been used by many researchers in the field of health in other countries. Then, the occurrence's number, intensity number, and diagnosis number of errors in the worksheet were recorded by benefiting the ideas of all insurance experts and the Province Health Center and number one township health center in person (considering that the training was presented before completing the worksheets). Errors were classified on the basis of outcoming critical index (from the result of multiplicating intensity, occurrence, and diagnosis numbers).
The ninth and 10 th steps including the move to eliminate or decrease the errors with high risk rate and second calculation of RPN resulting from reducing error states were not implemented due to the restrictions existed in the research.
In this research, data has been collected through observation and literature review, focus group discussion, and brainstorming technique in order to score the potentials of insured errors in the referral system based upon family physician. We get RPN (grades 1-5) by using the result of multiplications occurrence, intensity, and diagnosis number in order to analyze the data. Then, errors are graded based on high to low risk number (errors with high intensity number and at the same time having low risk number should be considered).
From a moral point of view, we assured the participants that the information is confidential and only the total results of the worksheets will be used.
| Results|| |
Participants in this study consisted of three experts from Isfahan Medical Care Insurance, 11 experts from the province's health center and number one townships, and three family physicians. In our survey, four main errors have been detected in the current referral system by family physicians in the first level of services including referring to a family physician in a noncovered area (not in the doctor's list), direct referring to a medical specialist, using medical services, and also noncontracted paraclinical services (such as laboratories and radiologies).
As [Table 1] illustrates, the critical index resulting from gathering the questioners and evaluating the given scores based on intensity, occurrence and diagnosis showed that the highest break point was for "receiving services from a noncontracted paraclinic", and the lowest one was for "referring to a doctor in a noncovered area".
|Table 1: Classification of important insured errors in referral systems of villages and towns populated under 20,000 in Isfahan city|
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| Discussion|| |
In this research we recognized the main insured errors or break point which brought about the disruption in accomplishing the program with the assistance of a group of experts in Isfahan Medical Care Insurance Office. Rasolinejad et al., (2001) in their article titled "Evaluating Referral System in Health Care Supplying System and the Solutions to Improve it in Kashan Network of Public Health and Medical Care" realized that based on referrer's sources; 46.3% of patients directly refer to specialized second level centers, 34.8% from the office of specialists, 7% by hospital emergencies, 4.1% by health centers, 2.4% by family physicians, and 5.4% have been referred by other sources.  Rohani (2000) also in his article titled "Evaluating the Condition of Patients' Reference to Hospitals of Mazandaran Medical Sciences University" argued that 82.5% of patients have been referred directly, 17.5% have themselves referred, and most of them were supported by Rurals' Public Medical Services Insurance Organization; 90% of referred patients have been informed of the logical connection between the hospitals and the local units, whereas this rate has been 35.6% in nonreferred patients.  The above mentioned researchers present that most of the errors in referral system are related to the patient (insured) and his high percentage of referring to a higher level of healthcare system. We recognized these errors in the current research. The current research has been accomplished after implementing the referral system based upon family physician and this is the reason to some differences which exists in the ones accomplished before implementing referral system based upon family physician.
Therefore, family physician has to refer the patients to a higher level in order to promote health just in necessity or many resources will be wasted.  Poorshirvani et al., in an article titled "Rural Insured People Get Acquainted with the Amenities, Criterias, and Conditions of Benefiting the Rural Health Care Insurance Notebook in Family Physician Program in Medical Sciences Universities Located in the North of Iran" have estimated the abundance of over 20-year-old insured people supported by family physician (62.3%). In the case of visiting a second level; demonstrating the results to the family physician (14.8%), receiving drugs only from the contracted pharmacies (72.4%), doing tests and radiologies in the contracted centers (47.8%), and visiting doctors in state hospitals and contracted specialists' offices by family physician's suggestion (54.6%).
Over 80% of family physicians stated that rural insured people wrongly request a second level due to lack of awareness about the determined criteria's, they ask for a lot of unnecessary drugs and also request for magnetic resonance imaging (MRI) unnecessarily. 
In the study conducted by Morrel it was reported that out of 1,000 people; 750 had been afflicted with a disease in their last 2 weeks. Five hundred people had self-care, 250 referred to a general practitioner, nine have been referred to a specialist, five people have been admitted to a community hospital, and only one has been introduced to a university specialized hospital in order to be admitted. 
| Conclusion|| |
According to [Table 2], in short, FMEA assembles the active detection of the probable break point in complicated processes, and is a foundation toward permanence improvement.
|Table 2: Evaluating the results of break points and the current control methods|
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| Acknowledgments|| |
This research is extracted from research program numbered 288257 approved by Health Management and Economic Research Center of Isfahan University of Medical Sciences. We give our best regards to advisors in the Faculty of Management and Medical Informatics, family physicians, and experts in Isfahan Medical Services Insurance Organization, and number one township health center that assisted the researchers to implement the program.
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[Table 1], [Table 2]