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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 2  |  Issue : 3  |  Page : 157-160

Evaluation of physician errors in the referral system of villages and towns populated under twenty thousand in Isfahan, using the (FMEA)


1 Department of Healthcare Management, Public Health Faculty, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2 Department of Management and Medical Information, Isfahan Medical Services Insurance Organization, Isfahan, Iran
3 Department of Health, Tehran University of Medical Sciences, Tehran, Iran

Date of Web Publication4-Oct-2014

Correspondence Address:
Noora Rafiee
Imam Hossein Sq., Public Health Faculty, Shahid Sadoughi University of Medical Sciences, Department of Healthcare Management, Yazd, Tel.: +98-9132269127
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-9019.142199

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  Abstract 

Introduction: As any large project, family physician and referral system program was also facing criticism in the executive process; in order to increase effectiveness of plan it is necessary to find and fix its criticism. In this research some errors occurred with of doctor have been identified by use (FMEA) method. Subjects and Methods: This was qualitative study identified the potential failure modes in this program by using group technique and brain storming. According to this, the researcher applied standard FMEA worksheet which is used by researchers and its consistency is assured and the validity is confined by authority professions. After consulting with urban experts of Isfahan province's treatment services in insurance organization in 2009, a suggestion about the family physician failures that have the highest priority number was proposed. Results : The highest and lowest risk priority numbers are the personal tendency of insured person to be referred to and having his or her book imprinted with the physician (33.83) and not referring the patient required to refer (12.86), respectively. Conclusion: In referring patients without need to refer, referral guidelines developed by the Ministry of Health; Getting a good deal of commitment that people want to refer to and consider the book closure period for these individuals and etc., can decrease these errors.

Keywords: Family physician, Failure Mode and Effect Analysis, risk, referral system


How to cite this article:
Rafiee N, Musavi MS, Kalantari E. Evaluation of physician errors in the referral system of villages and towns populated under twenty thousand in Isfahan, using the (FMEA). Int J Health Syst Disaster Manage 2014;2:157-60

How to cite this URL:
Rafiee N, Musavi MS, Kalantari E. Evaluation of physician errors in the referral system of villages and towns populated under twenty thousand in Isfahan, using the (FMEA). Int J Health Syst Disaster Manage [serial online] 2014 [cited 2024 Mar 28];2:157-60. Available from: https://www.ijhsdm.org/text.asp?2014/2/3/157/142199


  Introduction Top


Access to appropriate Facilities and Equipment is the most right of per patient and one international criteria at determining utility of treat level and it means that patient have right to benefit from family physician until ultra specialized services according their needs, respect to observance of referral system.

A good care have four features: A - The first level: Providing access to patient needs and mitigating unnecessary visit to experts, B - provide personal care over time, by the physician who responsible for the patient's entire care, C - Comprehensiveness of services, D - providing care for patients who need care out of primary level. [1]

Stephen (1981) in expression t1he importance of referral system declare that, significance cost of health care services (both financial and human dimension) spending in hospitals while 80-90 percent of patients compliances can be diagnosed and treat in the first level of care. [2] Coleman also in his studies acknowledged that 55 percent of patients with non-emergency health problem that went to emergency department, could be improved with receiving care or advice from general practitioner. [3] In Iran ''referral system program'' initiated in 1985 with implementation of service graded and expanding referral system but due to shortcoming, rural family plan and family physician in rural area and cities under 20000 population was emphasized. [4] This plan had some problems in implementation. a study that conducted in the northern province of Iran, that assessed that quality of referral system at 67% of cases is inappropriate, and it is evidence for this problem. [5]
"Failure Mode and Effect Analysis (FMEA) is a systematic method to identify and prevention of problem occurring in the process and services. This method has focused on prevention of error, improving safety and patient satisfaction. Accurate way in applying this method is that FMEA will implement in different stage of their design services, process or development. Use of this method has significant benefits. [6] This tool can prevent from errors that occur in referral system and provide opportunity that real users benefit from it.

Applying industrial engineering techniques in health care introduced with improving method of Fredrek Teylor principle's that named "principle of modern management". Nowadays in many of developed country applying engineering techniques in health care and health care planning, have expanded. Also in Iran, health care sector has implemented such program like quality management and organizational excellence systems.

Dominikey with applying this method in Bariatric surgery program, detected errors causes by failure during operation, which eventually led to reforms (such as dedicated team of nurses and anesthetists) to improve patient care. [5] Another study by Rasmin that examined the cause of death in two cases; identified mistake of nurse and her/his distraction as the most important factor and hence proposed suggestion for improving current situation. [5]


  Subjects and Methods Top


The present research is applied one, the study type is cross-sectional, and it is an qualitative 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 selection. 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 process, [7] referral system in villages and towns populated under 20,000 was selected in order to manage and organize the system better, considering the physician errors in the referral system, and the result obtained. [8]

In the second and third steps [7] (brainstorming for the potentials of errors and writing the potential effects of each error state), the main present errors of a physician in referral system and the plan of rural insurance was 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. [8]

We also discussed the effects of errors and the methods of controlling them in the fourth, fifth, sixth, seventh, and eight steps [7] (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 out coming critical index (from the result of multiplication 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. [8]

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. [8]


  Results Top


Findings of this study demonstrated that there are 4 current errors in the process of referral system in the first level of care by family physician that contains: Not referring the patient required to refer, referring patient that not need to refer, introduce to a specific specialist (relation-oriented), personal tendency of the insured person to be referred to and having his/her imprinted with the family physician [Table 1].
Table 1: Classification of important physician errors in referral systems of villages and towns populated under 20,000 in Isfahan city

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Critical index base on intensity, occurrence and diagnosis of collected data showed that the highest and lowest risk priority numbers are the not referring the patient required to refer and personal tendency of the insured person to be referred to and having his/her imprinted with the family physician, respectively [Table 2].
Table 2: Evaluating the results of break points and the current control methods

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  Discussion Top


Some facts about medical errors, most scholars have agreed on the following:

  • The error may occur because nobody is infallible, so errors should be limited in healthcare delivery system
  • Because of errors are predictable, the system must be designed so that they avoid or absorb them
  • Error is not synonymous with negligence. [9]


If we know error as failure of planned action to be completed or the use of wrong plan to achieve an aim, [10] and then categorized errors according to two types of causes: Active failure that can take the form of slips (doing a familiar action in the wrong way, like pouring salt instead of cream in to coffee), lapses (failure of memory such that planned actions do not happen) and mistakes (errors in reasoning that lead to wrong choices); we can suppose that family physician error is in the second category of errors.

In a study 330 errors of 50 family physicians were detected during a year, the highest error was related to communication problems between care provider and patients. [9]

In a study that monitoring performance of family physicians in Yazd, [11] patient tendency for prescribing drug by physicians was one of problems that consistent with third identified error in this study.

Also in study that assess satisfaction of villager of shahre-kord [12] about family physician plan, non-urgent refer to higher centers and lack of experience and skill of physician was identified as problems that corresponded to the first error of this study. Study of Porshirvani [13] explains that family physician in 28% of cases playing role in choosing of specialist of second level of care. Lankarani [14] also in his study found that family physician in Iran haven't adequate train for giving accountability in rural area and he suggest that establish of one compulsory training period in initiating of contract can be useful. Jannati and et al. described the strength and weakness of family physician and found that training of family physicians are inadequate that consistent with detected first and second error due to insufficient training to physician. [15]

Studies explain two main way in creating medical error:

  1. Error resulting in incorrect administration, which is solved by providing the proper administration
  2. Error caused by the clinical error that are caused by wrong service of provider and if we want to solve the problems caused by medical errors, providers will need to change their behavior. [9]


In this research we recognized the main physician errors; the error of referring patient that not need to be referred can be resolved with developing referral guidelines by the ministry of health are offered; at the time this study was designed20 guideline has developed and 50 guide lines also being developed.

The error of introducing patient to specific specialist, proper monitoring and giving the necessary notices can be useful; and for solving error of personal tendency of the insured person to be referred to and having his/her imprinted with the family physician getting a good deal from this patients and consider closure period for these people, preventing from decrease in income of provider due to observance of referral system, increase of income for provider can be reduced this error.

It seems if we will focus on reforms (trying to establish of referral system in the cities, the separation of public and private sector, revision of educational programs and training of family physician, precision drawing referral path, develop diagnostic and treatment protocols, adequate and efficient monitoring on treatment in the public and private sector) that solving challenges of referral system and family physician, the result will be worthwhile.


  Acknowledgments Top


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 family physicians, and experts in Isfahan Medical Services Insurance Organization.

 
  References Top

1.Reason J. Human error: Models and management. BMJ 2000;320:768.  Back to cited text no. 1
[PUBMED]    
2.Starfield B. Family medicine should shape reform, not vice versa. Fam Pract Manag 2009;16:6-7.  Back to cited text no. 2
    
3.Coleman P, Irons R, Nicholl J. Will alternative immediate care services reduce demands for non-urgent treatment at accident and emergency? Emerg Med J 2001;18:482-7.  Back to cited text no. 3
    
4.Nasrollahpour Shirvani SD, Ashrafian Amiri H, Motlagh MA, Kabir MJ, Maleki MR, Shabestani A, et al. Evaluation of the function of referral system in family physician program in Northern province of Iran: 2008. J Babol Univ Med Sci 2010;11:46-52.  Back to cited text no. 4
    
5.Nasseri Borabadi T. Risk management models in the medical records department in Alzahra Hospital: Identify and evaluate the potential failure modes and effects of its work processes. Thesis for a master′s degree in medical records. Isfahan Univ Med Sci 22:31-48.  Back to cited text no. 5
    
6.Mehraban R. Failure mode analysis. Tehran: Tehran Alborz Publication; 1998. p. 6.  Back to cited text no. 6
    
7.Gharachorlo N. Evaluation and risk management. Tehran: Oloom Fonoon; 2005.p 22-7.  Back to cited text no. 7
    
8.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 Disas Manag 2013;1:7-10.  Back to cited text no. 8
    
9.Diagnosing and Treating Medical Errors in Family Practice. CALIFORNIA ACADEMY OF FAMILY PHYSICIAN. Available from: http://www.familydocs.org" www.familydocs.org; 2002.  Back to cited text no. 9
    
10.Dovey S. Identifying threats to patient safety in family practice. AAFP Poster, 2000.  Back to cited text no. 10
    
11.Hafezi Z, Asqari R, Momayezi M. Evaluation of family physician performance in Yazd. Toloe Behdasht J Spring Winter 2008;6:16-26.  Back to cited text no. 11
    
12.Alidosti M, Tavasoli A. Satisfaction of Shahrekord Villagers about family practice program and its relationship with their knowledge. Zahedan Med Sci J 2011;13.  Back to cited text no. 12
    
13.Nasrollahpour Shirvani SD, Raeisee P, Motlagh ME, Kabir MJ, Ashrafian Amiri H. Evaluation of the performance of referral system in family physician program in Iran university of Medical Sciences. Hakim J 2010;13:19-25.  Back to cited text no. 13
    
14.Bagheri Lankarani K, Alavian M, Haghdoost AA . Family physicians in Iran: Success despite challenges. The Lancet;376:1540-1.  Back to cited text no. 14
    
15.Jannati A, Mleki MR, Gholizade M, Narimani MR, Vakeli S. Assessing the Strengths and Weaknesses of Family Physician Program. Knowledge and Health 2010;4:39-44.  Back to cited text no. 15
    



 
 
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Abstract
Introduction
Subjects and Methods
Results
Discussion
Acknowledgments
References
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