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
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
The four elements generally thought necessary to prove
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
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
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
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
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
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