1 Risk Management
2 Health care predictions from 3 years ago…how are we doing?The hospital as we know it will become extinct. The largest delivery system will be home health care In the next five years, the acute care inpatient census will be at least 50% of what it is today. Clinic services will be the second largest care delivery system. Clinics will be strategically placed in malls, schools and churches. Hospitals will be come triage centers with the primary objective of making rapid diagnoses and stabilizing patients. Most future inpatient units will be known as critical status units; the typical med-surg units will be virtually empty. Obstetrical care will shift from the acute care setting. Birthing centers will become vogue. Home births will flourish once again. All but the most complex surgical procedures will be done in free-standing outpatient surgery centers.
3 Physician Practice PatternsPhysicians will be active participants in some type of integrated delivery system. The most popular will be physician-hospital organizations. Fixed rate payment systems will force these partnerships Fully integrated care delivery systems will emerge. Physicians will become employees of organizations and are contracted to provide a continuum of services. Private physician practices will be a rarity.
4 More predictions Nonphysician providers will emergeReimbursement incentives will exist for organizations and group practices that use nonphysician providers. Focus to disease prevention, health promotion, and wellness. Great financial incentives for organizations and physician group practices to practice preventive medicine as health populations use less capitated dollars for care. Medical guidelines and protocols or pathways will be standard. A major focus on quality and outcomes will prevail. Network payers will stringently monitor quality and and outcomes. Driving force for all care delivery will be based on nationally acceptable patient outcomes and quality indicators. Full continuum of care services Case management will be used to move health care delivery into the next century.
5 Five phases of innovationPreparation Movement Team creativity New Reality Integration
6 The human side of change and transformationChange is often misguided and is introduced without attention to human needs. In the workplace today, employees are often performing at low levels of productivity and may manifest many signs and symptoms of job frustration. Employees are frustrated; they are being asked to change but are not being provided with reasons to change.
7 Allen and Kraft: four key principles for ensuring effective changeInvolve the persons who are affected by the change initiative Establish clear goals, objectives, purposes, and tasks Transform from a sound base of information Demonstrate concern for people and reward for achievement.
8 What do employees want when involved in change?To be respected, to be heard, to be listened to, to be understood, to be appreciated, to be involved in the change, to be valued, to be informed, to be allowed to express fears of change, and to be given a chance to understand the change and actively participate in it.
9 The responsibility of managementHumans are basically capable of 2 emotions, happiness and fear. People often express emotions at the anger or sadness level without fully understanding the underlying emotion. Exploration of the feelings of anger and sadness will result in the realization that fear was the underlying emotion. Fear is expressed in the active form of anger and the passive form of sadness. Must deal with the human side of change.
10 Outcomes to evaluate the people side of changeUnderstanding Acceptance Honesty (rumor mill does not exist) Belief Cooperation Fulfillment Professionalism Motivation Consistency Commitment
11 Risk Management…What is it?Protecting the assets of the organizations, agencies, and individual providers. Need to eliminate, mitigate, prevent, and defend against errors. Almost 1% of people admitted to hospitals incur an injury resulting from negligence while in the institution. Effective risk management program ensures a high quality of care and reduces or limits potential liability.
12 To survive and prosper, risk managers need to concentrate on managing uncertainty instead of managing exposures.
13 Risk management-a more comprehensive viewRisk management is the process of assuring that covered persons receive all of th4e health care services they need, to which they are entitled under the contract, no more and no less at the most cost-effective level possible by reducing or eliminating untoward incidents (occurrences) that might lead to injury or illness of patients, visitors, or employees.
14 Steps in the Risk Management ProcessRisk identification: collection of information about current and past patient care occurrences and other events that present potential loss to the institution. Examples of risk: antitrust violations, breach of contract, casualty exposure, defamation, embezzlement, environmental damage, fraud and abuse, general liability, hazardous substance exposure, professional malpractice, securities violations, transportation liability, and workers’ compensation. Not a static analysis.
15 Risk Analysis The evaluation of past experiences and current exposure to eliminate or limit substantially the impact of risk on cash flow, community image, and employee and medical staff morale. Need to consider the seriousness of risk.
16 Risk Control/TreatmentThe organization’s response to significant risk areas as well as its rejoinder to limit the liability associated with incidents that have occurred. (Most common function associated with risk management programs) Categorize the potential liability problems into 4 areas: bodily injury, liability losses, property loss, and consequential losses. Variety of methods and combination of techniques for controlling the risks: risk acceptance exposure avoidance loss prevention exposure segregation contractual transfer
17 Risk acceptance: facility decides not to purchase insurance against specific adverse events because the risk cannot be avoided, reduced, or transferred. Also, the probability of loss is not great and the potential fiscal consequences are within the institution’s capabilities to resolve. Exposure avoidance: rid the institution of the service, personnel, or equipment that may cause the loss. Loss prevention: use early detection and investigation & review medical records, incident reports, patient complaints and patient billing to pinpoint loss prevention areas. Loss reduction: usually involves management of claims and ensures that all records are preserved and that all personnel are prepared in the event of a loss. Settlements and releases conclude loss reduction efforts. Exposure segregation: separate out the exposure risks. Contractual transfer: shift the risk to the organization that provides the service through insurance or contract.
18 Minimal components of a risk management program (American Society of Healthcare Risk Management)Must be a designated, trained, & experienced risk manager who must obtain at least 8 hours of continuing risk management education annually. Risk managers must have access to all necessary credentialing, management and medical data. Institutions must commit the necessary resources to risk management through a written policy statement that is adopted by the governing body, medical staff, and administration. Facilities must have a system in place for the identification, review, and analysis of unanticipated adverse outcomes. Organizations must have the means to centralize risk management data and to share and integrate data collection and analysis with other clinical and administrative departments. At least annually, risk managers must provide the organization’s governing body a report that reviews and evaluates risk management program activity. Risk managers must ensure that medical staff and new employee educational programs on minimizing patients’ risks and addressing high-risk clinical areas are provided. Risk managers must forward information on individual practitioners, such as malpractice claim history, knowledge of adverse outcomes and incident reporting data, to the committees that evaluate the competency of medical staff.
19 Risk Red Flags Treatment conditions: poor treatment results, repetition of the problem, lack of follow-up care, equipment malfunction. Patient relations: dissatisfied patient, antagonistic patient or family members, complaining relatives, patient discharged against medical advice, intimidated patient, poor physician/patient relationship; poor staff/patient relationship. Practice management: poorly maintained medical records, lack of critical policies and procedures, and excessive volume of patients Conduct of staff: acting outside the scope of training, lack of qualified supervision, performance of a procedure for the first time without supervision, outspoken or rude behavior, personality conflict, and poor physician/staff relationship.
20 The do’s and don’ts of incident reportsDo record the details in objective terms, describing exactly what was seen and heard and nothing else. Do describe what actions were taken at the scene Do document the time of the incident, the name of the doctor notified, the time notified, and have the supervisor review the report. Don’t include names and addresses of witnesses, even if the form requests such information. (makes it easier for attorneys to sue the institution) Don’t file the incident report with the patient’s chart. Don’t admit liability or blame or identify others as responsible.
21 What are the risks in the workplace?Wrongful dismissal or discharge. Claims of defamation: purposely or carelessly, an employer disseminates incorrect or derogatory information about an employee. An employee alleging defamation must show that the information concerned the employee, that it was published or disclosed to others, that it is false, that it damages the employee’s reputation, and that the employer either acted negligently or had malicious intent. Arbitration may be an effective remedy. Problems that appropriately point to potential discharge include absenteeism, tardiness, carelessness, negligence, inappropriate dress or grooming, insubordination, theft, falsification of records, substance abuse on the job, or any deviation from practice standards. (remember due process)
22 Sabotage Consider keys, computer codes, and access to vital information. As soon as the employee is discharged, secure this information.
23 Discrimination law Primary federal statute is Title VII of the Civil Rights Act of 1964. Title VII prohibits discrimination on the basis of race, color, sex, religion, pregnancy, and national origin affecting the terms and conditions of employment. Modified in 1991 to allow for punitive damages for violations. Money is capped based upon the size of the employer. Be wary of jury trials. This is why many seek out-of-court settlements. State statutes often differ from federal are at often more prescriptive.
24 Burden of proof Litigants having the burden of proof are required to prove that their position is more correct that that of their adversaries. When both sides are equally as credible, the party who has the burden of proof is said not to have established his or her case. “Beyond a reasonable doubt” is the standard placed on the prosecution in a criminal case. In civil litigation, the burden of proof generally is on the plaintiff who must show a preponderance of the evidence.
25 Sexual harassment Unwelcome sexual advances, requests to sexual favors, or other verbal or physical conduct of a sexual nature when submission to such conduct is made either implicitly or explicitly a term or condition of employment. Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting that individual. Such conduct has the purpose or effect of unreasonably interfering with the individual’s work performance or creating an intimidating, hostile, or offensive working environment.
26 Prohibited questions during a job interviewDo you have a disability that would interfere with your ability to perform a job? How many days were you sick last year? Do you have a physical or mental impairment? Have you ever been treated for any of the following: AIDS, cancer, diabetes, epilepsy, heart disease, high blood pressure, or any other disease? Do you wear corrective lenses? Do you take any prescription drugs? If so, what? Have you been hospitalized in the past five years? Are you currently under the care of a physician or other medical practitioner? Have you been treated by a psychiatrist or other mental health practitioner? Have you every filed a workers’ compensation claim? Have you ever sustained a work-related injury? Have you ever been treated for drug addiction or alcoholism?
27 Most expensive and most common malpractice allegations5 most common malpractice allegations are: surgery/postoperative complications, failure to diagnose cancer, surgery/inadvertent act, improper treatment (birth-related), failure to diagnose fracture or dislocation. 5 most expensive settlements: improper treatment (birth-related), failure to diagnose hemorrhage, failure to diagnose myocardial infarction, failure to diagnose infection, failure to diagnose cancer.