Risk Management

Amelia Broussard, PhD, RN, MPHChristopher Gibbs, JD, MPH

Definition of Risk Management

• Identification, analysis, assessment, control and avoidance, reduction or removal of unacceptable risks.

• Includes:– Clinical services to avoid malpractice cases– Financial department to avoid financial losses through

poor billing practices or unfavorable contracts– Administration through personnel practices and lack of

compliance with policies procedures

• Lack of compliance with policies/procedures in all departments may lead to possible risk situations

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Strategies for Risk Management

• Proactive:– Looks forward, assesses functions, activities of

organization– Plans for risks in system and removes risks when

possible

• Example:– Risk management plan that encompasses all

departments of organization with assessment of possible areas of risk.

– Common risk is loss of power. Back-up generator reduces risk

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Strategies for Risk Management

• Retroactive:– Coordinated response to unexpected incidences in a

planned and logical manner to reduce risk and loss

• Example:– Patient receives the wrong medication

o Plan in place to review patient serviceso Plan includes steps to make sure that patient received

the correct medicineo Plan includes staff education and steps to reduce risk of

administration of wrong medication in future

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Example of Adverse Event in Clinical Area

• Patient submits malpractice claim stating that poor quality of care has left them unable to work due to health/mental health were damaged as a result of poor patient care.

• Patient has diabetes and chronic pain

• Organization did not have clinical protocols in place to manage diabetes and chronic pain.

• Peer review not conducted on regular basis

• QI/QA committee did not include peer review in minutes

• Credentialing/privileging policy/procedure not followed for provider assigned to as patient’s care giver.

• Recipe for disaster

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Analysis of Example of Adverse Event

• No clinical protocols outlining organization’s management of diabetes and chronic pain

• Peer review poorly documented and not included in QI/QA program

• Credentialing/privileging policy/procedure not followed completely when adding the provider responsible for patient care

• All of these issues could contribute to an adverse judgment against health center since policies/procedures were either not in place or not followed

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Risk Management Plan

• Governing board must commit to safety and quality

• Plan based on healthcare national standards and regulatory/program requirements

• Must fit organization’s services, area of practice, size and patient population

• Clear mission statement, goals, objectives, monitoring, problem identification, data collection, corrective actions and reporting to QI/QA and board as needed

• All staff members should be part of risk management

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Roles in Risk Management

• Governing board– Establishes corporate/regulatory/grant compliance

through policies– Oversees operation of organization through CEO– Documents oversight activities in minutes monthly

detailing activities that have been completed during that month

– Annual evaluation of board performance in meeting goals set in strategic plan, fulfilling requirements of oversight of organization

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Roles Cont.

• Administration– Implementation of organization’s policies/procedures– Ensures compliance with policies/procedures through

o Documentationo Claims managemento Contracts that benefit organization and patientso Insurance (property, gal, Director’s)o Public relationso Meeting regulatory/grant requirements

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Role of Finance Department

• Finance is part of risk management

• It should participate in meetings and present information as needed as part of the risk management department

• Finance should have policies/procedures that determine function of department

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Role of Human Resources

• Human Resources must assure that– Policies/procedure comply with regulations regarding

personnel– Job descriptions reflect appropriate duties, supervision

and compliance with ADA– Contracts are current, meet all requirements– Credentialing/privileging of all licensed independent

practitioners, other licensed/certified health care practitioners

– Employee orientation/health– Employee training requirements are met

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Role of Clinical Department

• Clinical department is a main focus of risk management

• Must assure– Clinical protocols in place to assure appropriate

management of patients– Quality improvement/quality assurance program in place

and monitoring patient care– Patient tracking and services provided for patients

through outside providers– Patient communications/satisfaction– Access to pharmacy services– Access to behavioral health

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Environment

• Organization must assure that patient care is delivered in a safe environment

• Must reduce possibility of accidents

• Maintain cleanliness

• Organization patient care to reduce exposure to infections either through poorly maintained equipment or staff practices

• Provide a disaster plan that assures safety of patients and staff in event of a natural disaster such as a tornado or hurricane

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Documentation of Risk Management

• Committee reports presented to QI/QA and board as needed

• On-going monitoring is documented in minutes of risk management meetings and QI/QA

• Solutions are developed through QI/QA

• Policies approved by BOD

• Procedures in place to support policies

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Risk Management in Deeming Application

• Several areas are addressed in application

• Relate to supervision of staff

• Tracking policies/procedures

• Other policies/procedures related to risk management

• Professional liability training for medical providers and also for other staff members

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Supervision of Clinical Staff

• Must submit a brief description of how supervision of clinical staff occurs

• Should include methods of supervising medical staff and reporting requirements

• Should include methods of supervising clinical support staff and reporting requirements

• Collaborative agreements for nurse practitioners and supervising agreements for physician assistants should also be discussed for each area

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General Requirements

• Organization provides for a periodic assessment to identify, prevent risks and monitor medical malpractice

• Written medical record policies/procedures for– HIPAA: training of staff to maintain privacy of patients– Completeness of record: documentation of demographic

information, income verification, clinical services rendered that includes medications, referrals, diagnostic testing

– Archiving procedures (relates more to paper records that are in storage, procedure should include process for destruction at appropriate time)

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Other Policies/Procedures

• Certification in application that following are in place and implemented:– Triage policy/procedure– Walk-in patients policy/procedure– Telephone triage policy/procedure– No show appointments policy/procedure (includes follow

up with patient documented in chart)

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Triage Policies/Procedures

• Certified only in application

• Organization should assure that all triage policies/procedures include– Who, what, when and response to phone or walk-in

patients– Appropriate staff should be assigned to triage patients

regardless of method of attempts to access care– Correct assessment during triage can reduce patient

illnesses and improve patient outcomes– Reduce possible situations resulting in malpractice

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No Show Policy/Procedure

• Common problem with health center patients

• Need to educate patient regarding need for medical care and appointments with providers

• Policy/procedure should include– Process for documenting no show in chart– Follow up with patients who did not keep their

appointments with documentation in chart – Attempts to re-appoint patient should also be

documented in chart

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Clinical Protocols

• Certification that clinical protocols that define patient care have been approved by board and are in place

• Clinical protocols should include:– Standard methods of providing patient care based on

national standards– Should be developed by medical staff to reflect patient

population and needs– Should include medications, lab testing with appropriate

intervals and other treatments that may improve patient outcomes

– Peer review is based on clinical protocols developed by medical staff and conducted on a regular basis

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Three Tracking Polices/Procedures

• Three tracking policies/procedures must be submitted with application:– Referrals– Diagnostic testing– Hospitalization

• All three policies/procedures should be approved by governing board at least every three years and when updated

• Tip: Timeframes and Responsibilities are should be key and should be stated in all three policies.

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Referral tracking Policy/Procedure

• Two types of referrals– Referrals to an outside provider– In-house referrals made between departments of

organizationo Example: physician refers patient to dental

department for care– Referrals in-house should be followed in same manner

as outside referrals

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Referral tracking Policy/Procedure

• Referral tracking designed to assure receipt of care not available in either department where patient initiates care or in organization

• Policy/procedure should:– Identify one person responsible for assuring that patients

receive care– Process for follow up of referrals– Time limit to wait for reports– Process to check with patients to determine if they have

received services– Process to re-appoint patients if needed– Documentation process in chart of results of referrals

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Tracking Diagnostic Testing

• Policy/procedure includes laboratory and imaging referrals

• Policy/procedure should:– Assign one person responsible for assuring receipt of

care– Time frame for follow up for results– Documentation in chart

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Information in Policy/Procedure

• Information needed for each diagnostic test– Patient information – Date test ordered– Ordering provider– List of tests ordered– Date results received– Provider who reviewed results– Follow up recommendation– Communication of results to patient

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Additional Components

• As part of diagnostic testing, policy/procedure should– Define critical, abnormal and normal lab results– Define a process for notifying providers and patients of

results especially for critical and abnormal results– Process should specify who will contact patient– How many attempts will be completed in trying to contact

patient and what form will attempts include

• Similar information must be present for imaging results that are considered critical or abnormal

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Tracking Hospitalization

• Most health centers do not admit patients to hospitals or follow them while admitted

• Tracking hospital stays is very important and should be documented in patient records

• Policy/procedure should– Define how a health center is notified of patient

admissions to hospital– Specify what information will be provided to health

center and how that is obtained– Notification of when patient is discharged– Specify who will follow up with patient after discharge

and when.

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Information in Policy/Procedure

• Following information should be in policy/procedure– Patient information– Date of admission or visit– Date of notification– Reason for visit, if known– Documentation received– Documentation requested (includes date requested)– Follow up initiated with hospital and/or patient

o Include date initiated

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Possible Strategies for Hospitalization Tracking

• MOA/MUA with hospital to notify organization when patients are admitted

• Develop relationships with admission personnel in emergency room and/or regular admissions office

• Assign one person to contact admissions office on a regular basis for possible hospital admissions

• Educate patients to notify health center when they are admitted

• Establish electronic links with hospitals to promote sharing of information and access to information on hospital admissions

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Continuing Education on Risk Management

• Continuing education and annual malpractice/risk management training has been included in this section

• Certification of a board approved training program for all health center staff on medical malpractice/risk management training

• Inclusion of all staff important

• Process should include roles of all staff, responsibilities (who will conduct training) and methods of tracking/documentation of training

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Sources for Malpractice/Risk Management Training

• One of the sources available free to health centers is ECRI

• Provides free CMEs

• Must register each individual who will access training

• May use website and information as source of risk management training for all staff/providers

• Information on QI/QA, developing tracking policies/procedures and protocols also available

• Access ECRI by web– http://www.ecri.org/clinical_rm_program (underscore

location between clinical and rm and rm and program)– E-mail: Clinical_RM_Program@ecri.org (underscore in

same locations as above)

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