Risk Management for Community Health Centers. Melinda S. Malecki, J.D., M.S.

Transcription

1 Risk Management for Community Health Centers Melinda S. Malecki, J.D., M.S.

2 Environment Medical Malpractice Crisis National Illinois second only to California California Medical Insurance Feasibility Study O utcome Screens Joint Commission on Accreditation of Healthcare Organizations Q uality Assurance Standards Risk Management Standards

3 Environment 21 st Century Medical Malpractice Crisis

4 Impact Nationally Com munity Loss of care - flight, higher risk specialties Increase in negative outcomes - lack of im mediate service Increase in dissatisfaction perception of industry Decrease in access - managed care provider pool

5 Impact Nationally Physician Increased cost - coverage / loss of coverage Higher settlements, increasing awards Loss of revenue - reduction in scope of services Increase in stress and decrease in job satisfaction Higher risk for patient satisfaction

6 Vidmar Study 2005 No upward trends Modest decrease in trials No increase in win rates between Caps effect would be very minimal Ob - Gyn and Neurosurgeons left state http: / / / medicalmalpracticestudy.pdf

7 Federal case in Illinois verdict $19,253,549 Bench trial Brain damaged baby

8 What is the difference between Quality Management and Risk Management?

9 Quality Management is process and outcome driven. Risk Management is ultimately financially driven.

10 Enterprise Risk Management Defined by the Risk and Insurance Management Society (RIMS) as the cultures, processes and tools to identify strategic opportunities and reduce uncertainty. ERM is a comprehensive view of risk from both operational and strategic perspectives and is a process that supports the reduction of uncertainty and promotes the exploitation of opportunities. Seven core com petencies: An ERM - based approach (executive support within culture) ERM process management (methods incorporated into culture) ERM appetite management (defines boundary of acceptable risk tolerance within the organization) Root cause discipline (degree of this discipline applied) Uncovering risks (degree of assessment within organization) Performance management (degree of executing vision and strategy) Business resiliency and sustainability (degree of integration into operational planning)

11 Elements of Risk Management Risk Identification Risk Analysis Risk Reduction Risk Maintenance

12 Risk Identification Examples of Incident reporting mechanisms Verbal reports Paper incident reports Electronic incident reports Claim Performance Improvement activities Incident report content The facts only

13 Risk Analysis 1. Gather information / data What happened Who was involved What caused it What was resulting condition to patient or staff What was done at time of incident to mitigate impact 2. Analy ze information / data Severity Frequency Legal potential Cost of more claims like this one

14 Risk Analysis 3. Balance costs of various measures against losses or lack of improvement expected if measures not in place Quality patient outcome and satisfaction, com munity service Financial Im mediate losses» Cost of fixing assuming charges» Subsequent remedial measures if not fixed Long term losses» Increased insurance costs» Decreased com m unity confidence» Negative publicity

15 Risk Analysis 4. Implement most reasonable solutions Action Plan Accountability Expectations 5. Document logic, decision making Performance Improvement Statistical Reports

16 Risk Reduction Methods used to reduce future loss. subsequent remedial measures

17 AKA Loss Control Risk Maintenance Managing information Scope How much can I handle Paper Electronic Minimum requirements Monthly statistical analysis of statistics Annual report is a good idea

18 The Bottom Line What leadership needs to see Comprehensive, understandable report to Board of Directors on loss control and improvement What management needs to see Continuous, understandable reporting on impact of performance on loss control and risk management What staff needs to see Periodic reports showing impact of daily actions on risk management

19 The Bottom Line What the carrier wants to see Early warning system Frequency and severity Forecasting IBNR - incurred but not reported Process and outcome improvement

20 Deeming Letter from the Bureau of Primary Health Care states: Malpractice coverage is based on the assurances provided in your FTCA deeming application with regard to 1) implementation of appropriate policies and procedures to reduce the risk of malpractice;

21 2) Implementation of a system whereby professional credentials and privileges... are reviewed and verified;

22 3) Cooperation with the Department of Justice (DOJ) in the defense of claims and action to prevent claims and

23 4) Cooperation with DOJ in providing information related to previous malpractice claims history.

24 Department of Health and Human Services O ffice of Inspector General s Report February 2005 Risk Management at Health Centers Report OEI http: / / oig.hhs.gov

25 HRSA s goal is that by 2010, 100% of health centers will participate in risk management training. HRSA plans to hold risk management workshops and develop a comprehensive training agenda.

26 HRSA Risk Management Requirements Active Q uality Im provement Program Appropriate use of clinical protocols Clear com munication with patients Com prehensive patient medical records Credentialing and privileging of health care professionals Formal patient grievance mechanism Regular patient satisfaction survey Regular staff training on risk management Up to date policies and procedures on risk management

27 Active Quality Improvement Program

28 Example of Quality Improvement Indicators

29 Laboratory! No orders! Mislabeled specimens! Lost, broken or unreceived specimens! Corrected laboratory reports! Specimen integrity issues! Incorrect tests ordered! Critical values not called to center

30 Pap Smear Tracking! % of women over 21 with Pap in last 3 years! % of Pap Smear results reported to patient in less than 30 days

31 Appropriate use of clinical protocols

32 Clear communication with patients

33 Comprehensive patient medical records

34 Credentialing and privileging of health care professionals

35 Formal patient grievance mechanism

36 Regular patient satisfaction survey

37 Regular staff training on Risk Management

38 Up-to to-date policies and procedures on risk management

39 HRSA not required but identified as important in the Inspector General s Report: Clear com munication with providers Documentation of informed consent Internal incident reporting system O ngoing peer review of patient cases Onsite assessment of risks and risk management practices

40 Clear communication with providers

41 Documentation of informed consent

42 Internal incident reporting system

43 Incident Reports Support with policy They are screens not medical records Educate staff about responsibility and reporting process Track and analyze for trends Facts only Avoid excessive narrative Avoid speculation and opinion Avoid casting aspersions (not for H.R. complaints) Should NO T be used for disciplinary purposes Should not be filed in personnel files Should not be included in medical records Should be marked as confidential

44 Investigations Endure that relevant information has been obtained Nature of occurence Nature of injuries Nature of potential allegations Sequester records and / or equipment if appropriate Document the scene (Signs in place? Water on the floor? ) Witness statements per se are discoverable but investigations are not discoverable No personal notes

45 Documentation of Incident in Medical Record Lack of documentation after an incident is a major reason why lawsuits have to be settled even in defensible cases Document what was done to take care of the patient to show immediate intervention, when MD called, when 911 called, etc. Description of occurrence should be strictly factual Patient found on floor in pool of urine Not patient fell due to incontinence Avoid entries that are self - serving Late entry may be ok discuss with Risk Manager

46 Ongoing peer review of patient cases The Healthcare Quality Improvement Act of 1986 created Federal law guidelines for peer review The Federal Statute provides immunity for physicians who act in good faith within the peer review process (no im munity for civil rights violations) All 50 states protect the confidentiality of peer review information The JCAH O requires ongoing peer review HRSA does not require peer review but strongly recom mends it.

47 In a 2005 study, participants in interviews cited peer review as one of the three most important tools for risk management but also one of the most difficult things to accomplish.

48 Starting a Peer Review Program Peer Review is an evaluation of the quality and efficiency of care ordered or performed by another practicing clinician with same or similar training and experience. It is a PROCESS that allows for ongoing monitoring and evaluation to establish open lines of communication among providers in an effort to achieve and maintain collaborative practice and facilitate positive patient outcomes.

49 Starting a Peer Review Program Designate a champion Establish a forum (e.g. a committee structure) for review of cases The forum should fairly represent the specialties The process should be educational; not punitive The forum creates the screens for the cases (what do you want to review? What do you want to learn and measure?) Non - physicians can apply the screens Data should be unidentifiable (e.g. do not use patient names) Keep peer review data as part of quality management data

50 Onsite assessment of risks and risk management practices

51 Additional indicators to monitor for exposure

52 Human Resources - Employment practices (criminal background checks)

53 Employment Agreements - Provider agreements - Medical Director Agreements - Legal Issues

54 Corporate Compliance (Business Practices)

55 Compliance Indicators - Days in A / R - Fraud and Abuse Compliance - Conflicts of Interest - HIPAA Compliance

56 Board Involvement

57 Contact Information: Melinda S. Malecki Lebow, Malecki & Tasch, LLC. Chicago, Illinois m malecki@lmtlaw.com