UT Southwestern Medical Center at Dallas

1. UT Southwestern Medical Centerat Dallas The Risk Analysis Process

2. The Risk Analysis Process • Identify departments • Compliance matrix worksheet distributed • Items added to Risk Matrix • Risks evaluated • University impact and probability determined • Risks classified as “A” or “B” • Monitors and owners confirmed

3. Assessment Data Gathering Sheet

4. The Risk Analysis Process • Approximately 300 risks identified • Initially 40 risks classified as “A” • The evaluation process is subjective • Human safety the most important evaluation criteria

5. Risk Matrix

6. The Risk Analysis Process • Monitoring & Training worksheets prepared for each “A” risk • Periodic reports to Compliance Committee scheduled • Results of monitoring • Training completed • Future plans

7. UT Southwestern Health Systems Physician Credentialing Provider Licensing – Risk 15 Failure to properly assure that health care providers are appropriately credentialed and licensed to practice medicine (including specialty) could result in harm to patients and loss of credibility for the institution. Rank – Grp 2 Responsible Party: President UTSHS Compliance Reporting to Compliance Officer and Committee Frequency: Annual Method: Report By: Ken Davis All practicing physicians must have a valid State of Texas Medical license to practice medicine. New physicians who have transferred from out of state are issued a temporary license with restrictions regarding practices. Compliance Goal: 100% of all practicing physicians must have a valid State of Texas Medical license to practice medicine. Risk Statement

8. Training Activities: ·         The Manager of Medical Services provides a review of Credentialing policies and procedures twice a year (Spring and Fall) to Departmental Liaisons. ·         The Manager of Medical Services provides one-on-one training to Departmental Liaisons upon request. Training Summary: Certification policies and procedures are reviewed twice a year with appointed Departmental Liaisons. Assurance Process: Physicians: ·         For new physicians, the physician’s department submits an enrollment package including a copy of the license to UTSHS. UTSHS tracks the enrollment package by date mailed and date received. Reports of outstanding enrollment packages are sent to the appropriate Departmental Liaison twice a month. ·         Licensing information is maintained at UTSHS where it is recorded along with the expiration date. ·         Each month a query of the database is conducted to determine licenses expiring in the next 30 days. Individual notifications are sent to the physician and the appropriate Departmental Liaison. ·         The UTSHS Credentialing staff validates license renewals on-line with the Texas State Board Medical Examiner (TSBME). When a license is validated, a hardcopy is printed and the database is updated. ·         If notice of renewal not received, the Credential Coordinator will contact the physician in an attempt to obtain the information. ·         If the renewal is not obtained at the end of the 30-day grace period from the TSBME, a letter is sent to the physician, the department chair, the Executive Vice Presidents for Clinical Affairs and Business Affairs indicating that the physician must discontinue practice until licensure is brought current. ·         The Credentialing Coordinator is responsible for the upkeep and maintenance of the physician licensure database. UTSHS owns the database. Risk Statement (cont.)

9. The Risk Analysis Process • Annual re-evaluation of “A” risks • Update Monitoring & Training worksheets • Perform assurance activities • Review priorities based on environmental changes