DDHA 8103 Week 11 Board Case on Moist Heat Example

Keep Moist Heat Under a Stop Rule: A Board Case That Sets the Quality Argument and the Liability Argument Side by Side for One Decision at a Twelve-Clinic Therapy Division

Student Name

Walden University

DDHA 8103: Advanced Healthcare Quality and Risk Management

Instructor Name

Month Day, Year

Keep Moist Heat Under a Stop Rule: A Board Case That Sets the Quality Argument and the Liability Argument Side by Side for One Decision at a Twelve-Clinic Therapy Division

The Request

The board's quality and safety committee is asked to approve one decision: that Hollins Ford Health's twelve outpatient therapy clinics continue to offer moist hot packs under Policy RH-214, subject to a stop rule. If two partial-thickness heat burns occur in any twelve-month period after the policy is fully in place, moist heat will be withdrawn from all clinics until the committee reviews the case again. The alternative before the committee is to withdraw moist heat now. Management recommends the first option. General counsel supports it with the conditions in the liability section and has reviewed this paper.

Background

Last spring a patient in his seventies was burned when he lay face up on a hot pack during a therapy visit. The review traced the injury to a habit shared by seven clinics, which grew up because the old procedure was silent about patients for whom lying prone is painful. Management has since adopted RH-214, which forbids placing a pack beneath a patient, requires fitted covers and a visual skin check, and limits each staff member to two simultaneous heat applications. Observed compliance with the positioning rule rose from 69 percent before the change to 96 percent in the most recent month, and no qualifying injury has been recorded in the 2,900 applications since the policy took effect. That run is too short to show the policy works, and this paper does not claim it does.

The Quality Argument

The quality case for keeping moist heat rests on its value to patients, and that value is real but modest. A review of trials found moderate evidence that continuous heat wraps reduce pain and disability in the short term for people with acute and subacute low back pain, and too little evidence to draw conclusions for chronic pain or for other forms of heat (French et al., 2006). Clinic hot packs are not identical to the wraps studied, and many of our patients have chronic conditions. The honest reading is that moist heat is a comfort measure with some support, valued by patients and used in about one visit in five, rather than a treatment whose loss would change outcomes.

That reading cuts both ways. It means withdrawing heat would not harm patients much in clinical terms. It also means that keeping heat is a choice to accept a small, managed risk for a modest benefit that patients clearly want. The quality argument for keeping heat is therefore conditional. It holds only if the controls work, which is why management proposes a stop rule rather than an open-ended commitment. The stop rule converts the question from whether heat is safe enough in principle to whether the division can show, with its own measure, that it has made heat safe enough in practice.

Withdrawal also has quality costs that are easy to overlook. Staff told the review team that when heat is unavailable, some patients ask for it repeatedly, some disengage from exercise and a few seek heat elsewhere without supervision. These effects are anecdotal and have not been measured. They are reported here because a committee weighing withdrawal should know them, not because they settle the question.

The Liability Argument

Counsel's concern is specific. Before last spring, the division could say it did not know that its practice was causing burns. It now knows. If another burn occurs after the board has chosen to keep moist heat, a claimant could argue that the organization continued a hazardous service after notice. Counsel's view is that this exposure is manageable, but only if the record shows that the decision was made deliberately, that the controls were adopted and followed, and that the organization stood ready to act on its own measures.

Three conditions follow from counsel's view, and management accepts all three. First, the decision and the stop rule must be minuted, with this paper attached, so that the record shows a reasoned choice rather than inertia. Second, compliance with RH-214 must be monitored and reported to this committee every quarter, including the per-clinic observation results, because a policy that exists on paper but is not followed would worsen the organization's position. Third, any new burn must be handled under the system's communication-and-resolution approach. Mello et al. (2014) found that such programs depend on counsel, risk management and insurers agreeing in advance on how disclosure and offers will be handled, and the division's liability carrier has confirmed in writing that it will consider early resolution for outpatient therapy injuries.

Counsel also noted a reporting point for the board's awareness. A payment made on behalf of a named licensed clinician in response to a written demand is generally reportable to the National Practitioner Data Bank, which affects how resolution offers are structured. That is an operational matter for risk management, but trustees should know that early resolution has consequences for individual clinicians that the program must handle carefully.

Withdrawal would remove this exposure for heat burns entirely. Counsel does not recommend it, because the exposure under the stop rule is limited and documented, and because withdrawing a service the moment it carries any risk would set a standard the organization could not meet across the rest of its services.

Where the Two Arguments Meet

The quality argument and the liability argument point to the same conditions from different directions. Quality wants a measured, time-limited test of whether the controls make heat safe. Liability wants a record showing that the organization chose deliberately and watched closely. The stop rule, the quarterly reporting and the minuted decision serve both. Neither argument has been softened to fit the other. The quality case admits that heat's benefit is modest; the liability case admits that keeping heat carries an exposure that withdrawal would avoid. Jha and Epstein (2010) found that hospitals whose boards gave quality a regular place on their agenda and reviewed performance data tended to perform better on quality measures, and this decision is an occasion for exactly that kind of oversight.

What the Committee Will See Each Quarter

Table 1

Quarterly Report to the Committee

The stop rule itself operates automatically; the committee does not need to meet for withdrawal to begin.

Alternatives Considered

Three options were weighed. Withdrawing heat now removes the exposure but gives up a valued comfort measure on the strength of one injury that the review traced to a correctable practice. Keeping heat without a stop rule is cheaper to administer but leaves the organization without a defined point at which it would act, which counsel regards as the weakest position. Keeping heat under the stop rule, the recommended option, accepts a limited and measured risk and commits the organization in advance to withdrawal if its own data show the controls are not working.

Conclusion

The committee is asked to keep moist heat in twelve clinics under Policy RH-214, with automatic withdrawal after two partial-thickness burns in any twelve months, quarterly reporting to this committee and a minuted decision with this paper attached. The quality argument supports the decision only because the stop rule makes it testable, and the liability argument supports it only because the record will show a deliberate, monitored choice. Both conditions are part of the motion.

References

French, S. D., Cameron, M., Walker, B. F., Reggars, J. W., & Esterman, A. J. (2006). A Cochrane review of superficial heat or cold for low back pain. Spine, 31(9), 998-1006. https://doi.org/10.1097/01.brs.0000214881.10814.64

Jha, A., & Epstein, A. (2010). Hospital governance and the quality of care. Health Affairs, 29(1), 182-187. https://doi.org/10.1377/hlthaff.2009.0297

Mello, M. M., Boothman, R. C., McDonald, T., Driver, J., Lembitz, A., Bouwmeester, D., Dunlap, B., & Gallagher, T. (2014). Communication-and-resolution programs: The challenges and lessons learned from six early adopters. Health Affairs, 33(1), 20-29. https://doi.org/10.1377/hlthaff.2013.0828