delineation of provider responsibility for treatment and follow-up of test results. But some have asked what is the content in the four steps? Learn more about policy and procedure management for hospitals. How should they be organized? It involves identifying and evaluating risks, in addition to implementing the most advantageous methods of reducing or eliminating them. Sample Risk Ma nagemen t Policy and Pro cedure. Assess the flow of patients through the office to determine how best to maintain the privacy of PHI. This process should include a provision to sequester any piece of equipment which may be directly involved in injury to a patient, staff, or provider. a risk management framework is maintained, which provides assurance to the Board that strategic and operational risks are being managed risk management is an integral part of NHS Resolution culture and encourages learning from incident risk associated with the health, safety & wellbeing of staff, fraud, project and programme . However, potential risks arise when: a) the organizations policy differs from the cited professional guidelines or omits some key element noted in those guidelines; b) If the cited professional guideline is updated following issuance of the policy, and the organization has not updated the policy accordingly. Standardize practices across multiple entities within a single a health system. Diagnostic and interventional equipment that can accommodate morbidly obese patients should be available. Over the years, we have seen a number of lawsuits filed against physicians by close friends, colleagues, and even their own family members because of care provided by our insureds. Effective communication with patients may improve compliance with treatment regimens, enhance the informed consent process, and increase safe medication use. Become knowledgeable about the requirements regarding any restrictions on discharge imposed by the third party payors with whom you participate. O = Orient the patient to what you are doing, I = Information gathering allowing time for conversation, S = Share what you are looking at on the screen with the patient, E = Educate the patient, reinforce the plan of action, D = Debrief and assess the degree to which the patient understands the recommendations and plan. 4. risk financing. The following tips will help you successfully and appropriately respond to negative online reviews: The Risk: As the use of electronic health records (EHRs) has become widespread, documentation practices and workflow patterns have changed significantly and have added to a growing clinical and administrative workload. Other Responsibilities Risk managers assist hospital trainers and department managers with educating employees about risk, liability and risk management policies and procedures. The Department of Health and Human Services states the r isk management definition as: " any activity, process, or policy to reduce liability exposure" with an emphasis on "preventing harm to patients and reducing medical malpractice claims." The patients medical record should be reviewed in conjunction with these requests in an effort to assess the potential for medical malpractice litigation. The Risk: The receipt and review of test results are important aspects of patient care and safety in physician practices. A policy management software solution can provide this kind of centralized, "single source of truth" access. However, healthcare professionals must be aware of the potential risks presented by this technology. Creager, R. T. (2008). The use of this technology has increased the amount of time necessary to complete medical record documentation and order entry. Consider using non-printed materials, such as videos and audio recordings, as indicated. The presence of a chaperone must always be documented in the patients medical record. Perform and document a thorough initial evaluation of the patient. The answer depends on the laws in effect in the jurisdiction where the health provider organization is located, the scope of its peer review privilege statute(s), if any, and precedent-setting judicial decisions. Continued failure of a patient to keep appointments may be deemed non-compliance with treatment. Administrative and HR<\/span><\/strong>. When electronically issuing or writing a prescription for controlled substances, write the quantity and the strength of drugs in both letters and numbers to prevent alteration. Policy and Procedures - Risk Management. . HIPAA, EMTALA, CMS Conditions of Participation, DNV/Joint Commission). Cardiac Heater - Cooler Management Policy . Providers should not use the portal as the means to communicate critical/significant diagnostic results. The Risk: Effective communication is the cornerstone of the doctor-patient relationship. 1.1 This policy is part of a suite of policies that enables the delivery of the NHS Fife Risk Management Framework. The provider also should review pertinent diagnostic studies, previous interventions and drug history and assess the extent of co-existing medical conditions which impact the patients pain. The Risk: Healthcare communication continues to become more electronic, and while social media accounts tend toward a more casual communication style, healthcare providers must remain vigilant about the security of their platforms, as well as the message they convey to their patients and potential patients. When this occurs, internal controls, such as the development of high risk policies and procedures, can be incorporated to better manage risks. Consider the health literacy level of your patient. And when updating policies, be sure to ask the people who actually work in these areas for ideas and suggestions on how to improve. Moving to a cloud-based policy management solution is critical to healthcare policy and procedure management. While some negative statements regarding the performance of you or your staff may be difficult to read, evaluate these reviews to determine if there is any opportunity for learning or process change. Biomedical Instrumentation & Technology, 49(6), 433-435. Put the policy title/number in the header of each page. 1.2 It describes the current responsibilities and procedures to be followed in the process of risk identification and assessment and the development and maintenance of risk registers in NHS Fife. In addition to the reasons we discussed for hospitals, student health services are also able to operate more efficiently. Travel to QMC > City Hospital Hucknall Road Nottingham NG5 1PB. Dissatisfaction with medical care may be a harbinger of medical malpractice litigation. 2See MLMICs Risk Management Tip #20: Reducing the Risk of the Copy and Paste Function in Electronic Health Records. Educate your staff regarding patient follow-up processes in your practice. How do we keep track of all the risks while proceeding with the four steps in the compliance plan? The policy applies to. What risks do we need to take to the CEO and the board? A process should be in place for maintenance of medical equipment. 1. The risk management process involves five key steps which are outlined in . Discover how PowerDMS is specialized for the needs and challenges of organizations like yours. That may invite a plaintiff lawyer to take a statement out of context and allege that it places an obligation on the defendant that was not intended. Abnormal test results requiring follow-up present an additional risk if they are not received, reviewed, or communicated to the patient. Physician practices should have policies and procedures in place for the management of test results. They even cover HR and IT policies for those groups. Even though there are different types of healthcare organizations, healthcare policy and procedure management is still one of the most important issues on their plate. Staff conversations regarding patient care should not be audible to patients and visitors in the waiting area. All staff should know to whom complaints should be addressed, as well as what information constitutes a complaint that requires attention or intervention by that person. Physicians and other healthcare providers need to identify the reasons for noncompliance and document their efforts to resolve the underlying issues. The operational challenges associated with drafting (and maintaining) comprehensive written policies place heavy demands on healthcare managers. keep an accurate list of all medications including generic and brand names, over-the-counter medications, and herbal supplements, which includes dosages, dosing frequency, and the reasons for taking the medication; maintain a complete list of medical providers and their contact information; post the name and telephone number of their local pharmacy in a prominent location along with the name and phone number of their physician; establish a daily routine when taking their medications; and. The risk analysis described in Section 3.3 (see Risk Register) and the risk evaluation system described in Section 3.1.5, can be used to determine whether a risk is acceptable or needs to be eliminated.Risks deemed to be low or acceptable may only need to be minimized via simultaneous monitoring and regular checking, while risks deemed to unacceptable need to be eliminated or avoided. How Does it Work? Second, the use of chaperones can provide legal protection for the physician in the event of a misunderstanding or false accusation of sexual misconduct on the part of the patient. Implementing appropriate policies and procedures in the use of portals will enhance patient communication and mitigate liability risks for the practice. Disparate policies can expose organizations to risk because a plaintiff lawyer may allege that one entitys policy was less comprehensive than the others and thereby represented a lower standard of care. 3. Compliance programs should effectively articulate and demonstrate the organizations commitment to the compliance process. If a patient has been non-compliant in obtaining the recommended consultation, follow-up is necessary. But some have asked what is the content in the four steps? If there is no response from the patient or the patient develops a pattern of not keeping or missing appointments, a letter with a certificate of mailing should be sent to the patient to advise him/her of the risk of non-compliance. These groupings were based on OIG Guidances; the subjects of investigations and CIAs; the areas of overpayments identified by Program Safeguard Contractors (PSCs), and more recently,Recovery Audit Contractors(RACs); and Congressional testimony given by OIG, CMS, FDA, NIH, and others. Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings. First, it may provide reassurance to patients, demonstrating both respect for their concerns and an understanding of their vulnerability. Download The Future of Policy & Compliance Management report. Subcategories may include: stabilization, signage, physician on-call response, transfer, medical screening exam, and medical emergency response to areas outside the hospital buildings and non-clinical areas within the hospital. Professional association recommendations lack the authority of statutes or regulations, making them advisory rather than mandatory. Give appropriate feedback to patients to encourage healthful changes in behavior. The Anti-kickback Statute and Stark Law have been consistently and vigorously enforced by OIG and DoJ. The Risk: The copy and paste function of electronic health record systems (EHRs) allows users to easily duplicate information such as text, images, and other data within or between documents. 4. When there are multiple hospitals within a health system, there is little justification for allowing each hospital to independently develop its own policies. A healthcare organization's human resource management department handles a variety of responsibilities related to the internal health of an organization. learning lessons from adverse events and poor outcomes. You can also check their knowledge with customizable testing to ensure they all know and understand your policies, especially those related to new standards. The confidentiality of minors information. The Journal of Epidemiology and Preventive Medicine outlines five basic steps of risk management in healthcare: Establish the context Identify risks Analyze risks Evaluate risks Treat/manage risks As a result, we have settled on ten broad categories that we think represent all major risk areas, have long-term implications, and are concise enough to present to CEOs and board members. Protect prescription blanks if still utilized in your practice. It helps them set standards and best practices, create rules that staff members are expected to follow, and mitigate risk and reduce liability against lawsuits and regulatory problems. Providing care under these circumstances may pose unique risks. Failure or malfunction of this equipment may lead to patient, staff or provider injury. Then it's just a question of sharing that information with the accreditation agencies, and it can shave months off the time. We realize that not all ten categories will be applicable to all facilities. For instance, stating that X action shall be taken does not specify which staff member is responsible for carrying out the task. However, we cannot discuss specific situations due to patient privacy regulations. Prepare a contingency plan for use in case of a technology failure. The federal government passed the Emergency Medical Treatment and Active Labor Act (EMTALA) in order to require hospitals to offer treatment to all persons who seek care. Physicians offices may not be well equipped to accommodate patients of size. If an employee transfers to a different job function, have a process in place to reduce or increase their access based on the new job functions. CH1 Management of Asbestos Policy [pdf] 418KB. Student health services administrators often say management issues are the biggest challenges they face, and that can include poor patient outcomes, governmental mandates, and ethical issues. Even though these visits are conducted remotely, be cognizant that the patient will also be able to visualize the encounter. Physicians should be notified of all missed or cancelled appointments on a daily basis. Grant staff access to an EH only on a need to know basis: Individuals should be granted access only to the information necessary to perform his/her job. The Risk: The communication of test results is an important part of providing care and may involve various healthcare professionals. Include key staff and providers in the selection process to determine the best system for your practice and patient population. Failure to do so may cause a staff member to follow an outdated policy, possibly comprising patient care as well as potential allegations of corporate negligence. The overall goal in healthcare risk management in both situations is to minimize the risk of: harm to our patients; liability exposure of our health care providers; financial loss to the agency This time period may be longer depending on the patients condition and the availability of alternative care. Understand and maximize the format and function of your EHR. Increase communication and access through media such as: Information sheets and/or flyers in the office, Regularly update all electronic devices and applications as recommended. The Department of Justice (DoJ) issues press releases about health care providers who have been convicted of crimes. The presence of superlative adjectives is sometimes alleged by plaintiff lawyers to be a guarantee of a certain outcome. Pharmacy policies cover a range of topics including prescription protocols, outpatient prescription availability and drug sample protocols. Note other policies on a similar subject that may be useful at the end of the policy, for cross-reference purposes. Incorporate word search functionality in order to facilitate searches for pertinent policies irrespective of their issuing domains. The online community, however, is then afforded an opportunity to respond, rate, and, at times, complain about those services. Medication Safety Alert! In some cases, many of them don't have continual access to a computer where they can access their policy manual when they have a chance to sit down. Document the patients informed consent for treatment of chronic pain with controlled substances. The organization has a duty to inform all affected personnel prior to the effective date of a new or revised policy. A chaperone should be provided even if the provider is the same gender as the patient. Updated: December 2020. Document the problems that have led to the discharge in the patients record. Keep letters of response to complaints concise and simple. This may include telephone and/or electronic communication. Follow-up procedures should be an integral part of your practice and can help ensure that patients obtain the necessary testing, as ordered, and that results are received, reviewed and properly addressed. 431 KB. Policies the organization had in effect were contradictory to other organizational policies, differed across entities in the same system without a basis for the difference, or were inconsistent with applicable regulations. Risk management advisors have the responsibility of creating a plan that includes all practices and procedures and meets the demands of all interested parties. The scope of practice of medical personnel/licensed staff must be considered when they perform or assist in a procedure and/or use medical equipment. In a prior article, Refocusing the Compliance Paradigm, that appeared in the April 2008 issue ofCompliance Today, we laid out the following four steps in the compliance process: risk assessment, risk remediation, risk auditing, and risk response and reporting. Extenuating circumstances may also necessitate adaptation. The Risk: Patient satisfaction is an integral part of providing healthcare, regardless of the clinical setting. Although patients of size may face many additional medical issues, they are less likely to obtain preventative care and more likely to postpone or cancel appointments because of embarrassment and/or a feeling of bias on the part of healthcare providers. Respect for the patients privacy can be further maintained by speaking to the patient privately before and/or after the examination. Passwords should be changed at set intervals. The Risk: Patient noncompliance is one of the most difficult challenges for healthcare providers. If the patient is unable to convey the information, it should be restated in simpler terms, perhaps utilizing pictures and/or drawings. Human resources policies and procedures Our organisation Nottinghamshire Health and Care Portal Regulatory information Equality, Diversity and Inclusion . Although the American Medical Association advises physicians not to treat immediate family members except in cases of emergency or when no one else is available, this practice continues to occur. As the technology and science around healthcare change, so do the industry standards. Subcategories may include: privacy, security, information technology, and documentation. Verify that the diagnoses in your assessment are only those addressed at that visit. Generate and retain formal documentation of all telehealth patient care visits. Have written policies and procedures to address: How patients and their representative can access their health information. Rather than printing out thousands of policies and putting them in hundreds of binders, you can share your manual updates electronically, track the readership of the policies, and even check signature verification. Properly discharging a patient from care can be a complex issue. Identify policy disparities and develop a plan for standardization, unless there are legitimate reasons why the systems current policy needs to be modified in whole or in part, because of different jurisdictional statutes or different services offered by a particular organization. Confidentiality agreements should be signed by all staff members. A record of all maintenance activities should be generated and retained. Inform patients about the indications for the test(s) and document this conversation in the medical record. Review the organization of files stored on your devices: Determine that you have the right information and applications on the right device, Define those files that are mobile, laptop, and PC-appropriate, Know how to disable, lock, or erase information in the event of device theft, Use multifactor authentication (MFA) for logging into your social media accounts, Lock down who can see your posts/information. Second, and perhaps more importantly, if the treatment given in a specific case followed the less rigorous of the two policies, a plaintiff who suffered harm may allege that his/her care did not fulfill the legal standard of care.. In every hospital and health system, risk managers are the go-to resources for answers to a range of safety, quality, and compliance questions. Physicians must discuss the indications, risks, benefits, and alternatives of prescription medication with their patients and document these discussions in the medical record. Written consent should be obtained for high risk medications such as allergy shots, joint injections, fertility medications, chemotherapy, etc. Incorporate training about policy and procedure compliance in new-employee orientation programs. Definitions. The use of answering machines or voicemail systems for after-hours calls is not recommended for the following reasons: There are no safeguards in the event of a malfunction. This should include: a history and assessment of the impact of the pain on the patient; the nature, type and causation of the pain; and a focused physical examination to determine if there are objective signs and symptoms of pain. Destache, D. M. (2013, April 30). EF1 Space Utilisation Policy [pdf] 705KB. 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