Risk Management Program

Risk management is an important element of the quality 
assessment/performance improvement process; an effective risk 
management program protects not only the life and welfare of 
the employees, provider staff, patients, and visitors but is 
concerned with the overall well-being of the business entity.
Risk management is a systematic program which encompasses 
every aspect of our organization; the goal of the risk 
management program is to reduce preventable injuries and 
accidents and minimize the financial severity of incidents.  
It involves identification of potential problem situations 
with an emphasis on claims prevention and includes a 
heightened sensitivity to the emotional needs of patients.
This risk management program is intended to eliminate 
conditions that could result in various types of claims 
against the organization and its providers, as well as to 
minimize the severity of claims once injuries or losses have 
The following components for the risk management program have 
been identified: 
Professional Liability 
Professional liability if a major potential hazard to which 
this, and any, health care organization is vulnerable; the 
number of malpractice cases has risen dramatically during the 
past decade. The genesis of this growth probably is in the 

public's increased knowledge about the litigation process and 
the possibility of monetary gain; and, heightened 
expectations regarding outcomes.
Poor communication is one of the most common reasons for 
litigation; other lawsuits commonly relate to inadequate 
supervision, failure to diagnose/misdiagnosis, unrealistic 
expectations of medical care on the part of the patient, and 
unexpected--albeit natural--outcomes.
The four elements generally thought necessary to prove 
malpractice are:
1.  The provider must owe a duty of care to the patient.
2.  There must be a breach of that duty or, in other words, 
    failure to deliver a service.
3.  This failure to deliver a service must be the proximate 
    (or the immediate) cause of the injury.
4.  The injury must be measurable.
A periodic review of all litigation involving the 
organization and any of our providers is conducted at the 
governing body level.  Similarly, every patient complaint is 
treated with the utmost concern; when appropriate, the 
professional liability carrier is involved in the decision 
making process regarding disposition of such complaints.
Incident Reporting Mechanism
The risk management program includes an incident reporting 

component which involves measures to assure good 
documentation, prudent clinical practices, appropriately 
trained staff, and effective management of at-risk situations 
which may develop. 
In the outpatient setting, unusual occurrences are typically 
identified by:
1.  Incident reports completed by involved staff members. 
2.  Reports from other individuals aware of the incident. 
3.  Letters or telephone calls from staff members, or from 
    patients or their families. 
4.  Review of the medical record.
Factors relating to all reported incidents addressed by the 
risk management program include:
1.  Prompt identification/reporting, and 
    investigation/reviewing, analysis and intervention 
    relating to specific incidents. Whether reported by 
    employees, patients, health care professionals, and/or 
2.  Early intervention and sympathetic care after any 
    untoward event.
3.  Preparation of detailed, useful incident reports.
4.  Definition of the cause of each incident.
5.  Evaluation of the frequency and severity of untoward 
6.  Formulation and implementation of efficacious,
    corrective actions to reduce risk and limit potential 
7.  Fastidious attention to safety at every level.
An impaired or incapacitated provider, professional staff 
member, contracted individual or employee is a reportable 
incident; the protocol for dealing with such incidents is 
outlined in the Clinical Manual, 'The Impaired Physician or 
Staff Member' and 'The Incapacitated Physician or Staff 
Member'.  Similarly, dealing with the impaired patient can be 
difficult for involved staff; the protocol for such action is 
outlined in the Clinical Manual, 'The Impaired Patient'.
An important component of risk management to which we are 
extremely sensitive is an awareness of patient outcomes.  We 
have an active patient satisfaction survey protocol and are 
sensitive to possible patient dissatisfaction when reviewing 
delinquent accounts with consideration of proceeding with 
collection action.  To this end, all accounts are reviewed by 
the Medical Director, or his/her designee, before aggressive 
collection activity is undertaken.
All staff members are aware that not every patient is 
appropriate to our care model.  Refusal of care, and/or 
leaving against medical advice or dismissal of any patient 
from our health care delivery situation are critically 
important elements of our risk management program which are 
handled at the management level (see Administrative Manual, 
'Dismissal of Patient from Care'.
Should a patient leave against medical advice; all 
particulars leading up to the patient leaving will be 
documented and the organization's legal counsel will be 
notified, please see Policy Guideline: Discharge of Patient 
Against Medical Advice located in Volume 3. 
Medication errors and prescriptions are a source of potential 
problems.  The practice of pre-signing prescription blanks or 
signing incomplete prescriptions must be avoided.  
Prescriptions can only be issued after completion of a good 
faith history and physical examination; every effort must be 
made to identify and thwart patients who are drug-seeking or 
otherwise seeking to divert prescription medication. 
Business-Related Risk Management Considerations
Risk management is often considered to be patient-driven.  An 
important aspect of risk management is our relationship with 
other specialty-specific providers in our area.  We are very 
cognizant of the need to maintain good inter-office and 
intra-specialty professional relations while preserving the 
boundaries necessary to preclude any semblance of 
price-fixing or other anti-trust related or professional 
ethics violations.
Role of the Quality Management Coordinator (NOTE:  Quality 
Management functions may be divided among several staff 
The Quality Management Coordinator is responsible for 
consistent application of the Risk Management Program 

throughout the entire organization, under the direction of 
the Staff Executive Committee. 
Responsibilities include: preparation of meeting minutes, 
facilitation of follow-through of Committee activities, and 
accomplishment of specific projects.  Routine activities 
include review of the following reports:
1.  ALL incident reports;
2.  ALL reported deaths, trauma or other adverse incidents
   (see the Sequella Monitoring Record) 
3.  ALL Actual and potential infection control occurrences
    and breaches not limited to surgical site infections
4.  All patient satisfaction surveys; 
5.  Reports of phone calls or other verbal complaints, 
    whether documented on an incident report form or not; 
6.  Status of all known litigation and all potential 
    malpractice actions (as identified through the request 
    for records or preliminary notices from attorneys);
7.  Communications with the professional liability insurance 
8.  Communication with the media; anything that would 
    jeopardize patient confidentiality will not be 
    discussed.  Other communication with the media in regards 
    to procedures, innovations, or public relations will be 
discussed with the organization's attorney for legal  
    advice and avoidance of conflict of interest.
9.  Communication with governmental agencies; i.e. OSHA,
    Department of Health, DEA, etc.  will be handled by the 
    Medical Director.  Depending on the nature of 
    communication, the organization's attorney or the 
    malpractice attorney may also be involved.
10.  Review of patient charts for problems with outcomes 
    before any accounts are aggressively pursued for 
    collection purposes.
Additionally, the Coordinator will periodically review 
clinical records and related policies to insure the following:
1.  Records are retained in accordance with State and
    Federal law; and there has been no breach of private 
    health care information.  If there has been a breach 
    assurance that all requirements have been met according 
    to HIPAA regulations.
2.  Objectivity is maintained in recording of observations 
    so that inappropriate remarks are not recorded;
3.  Records are released only with the appropriate written 
4.  Records are legible and signed by the responsible 
    practitioner; and
5.  Documentation is complete.
This organization is subject to the highest standards of 
medical ethics and strives to operate within the paradigm of 
the regulatory agencies to which we are subject.  Additional 
information regarding this aspect of our risk management 
program is contained in the policy, 'Legal and Ethics 
Oversight and Regulatory Disclosures', in the Governance 

Approved By Governing Board
Control #11.12