1. Amelia Broussard, PhD, RN, MPH Christopher Gibbs, JD, MPH
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
(underscore location between clinical and rm and rm and program)
(underscore in same locations as above)