Risk Management

1. Risk Management Amelia Broussard, PhD, RN, MPH Christopher Gibbs, JD, MPH

2. 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

3. 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

4. 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 • Plan in place to review patient services • Plan includes steps to make sure that patient received the correct medicine • Plan includes staff education and steps to reduce risk of administration of wrong medication in future

5. 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

6. 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

7. 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

8. 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

9. Roles Cont. • Administration • Implementation of organization’s policies/procedures • Ensures compliance with policies/procedures through • Documentation • Claims management • Contracts that benefit organization and patients • Insurance (property, gal, Director’s) • Public relations • Meeting regulatory/grant requirements

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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)

18. 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)

19. 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

20. 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

21. 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

22. 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.

23. Referral tracking Policy/Procedure • Two types of referrals • Referrals to an outside provider • In-house referrals made between departments of organization • Example: physician refers patient to dental department for care • Referrals in-house should be followed in same manner as outside referrals

24. 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

25. 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

26. 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

27. 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

28. 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.

29. 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 • Include date initiated

30. 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

31. 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

32. 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)