Health Care Risk Management: Assignment Week 6

Chapter 15: Risk Management in Ambulatory Care Settings

Ambulatory Settings

• There has been a steady flow of clinical services out of hospital settings into more cost-effective outpatient settings

• Risk management is as important in the outpatient setting as it is in the inpatient, especially as outpatient settings are not subject to accreditation

• Of all paid malpractice claims, a greater number are coming from the ambulatory setting than from inpatient alone

Why the increased risk?

• Ambulatory settings differ from inpatient in that they do not have the same mix of specially trained professionals managing patient care 24 hours a day including detailed documentation, observation, decision support teams

• Ambulatory setting provides infrequent care spread over time and patients are generally seen by personnel with a lower level of training performing tasks in multiple areas

Assessment of the Practice Setting

• Risk Managers need to assess the risks inherent to the specific site

• Management of risk in the ambulatory setting sites on 3 core principles:

– A culture of safety

– Good employment practices

– Ethical business practices

Culture of Safety

• It is important to recognize that human errors are inevitable and leads to ways to strengthen the system of care rather than punishment

• 4 Key Features

– Psychological safety

– Active leadership

– Transparency

– Fairness

Good Employment Practices

• Under the principle of vicarious liability, the facility owner is legally responsible for the actions of their employees

• Potential risks:

– Non-physician employee exceeding their legally authorized duties

– Inappropriate actions of employees

– Fair employment practice issues

Ethical Business Practices

• The risk manager must guard the practice against fraud and abuse by ensuring

– Appropriate billing practices

– Compliance with Stark Law

– No inappropriate upcoding of claims

High Risk Areas

• Missed diagnoses

• Medication risks

• Infectious risks

• Communication

• Documentation

Office Management

• Clear and regularly updated policies and procedures will help maintain high standards of patient care and lower the risk of lawsuits

• The Policy and Procedure Manual should be available to all employees and follow the mission, vision and values of the practice setting.

Policy Manual Section – Administration

Describes the organization of the practice setting – Hours of operation – Holidays – Emergency contact after hours – HIPAA – Patient Rights (including children) – Patient responsibilities – Missed appointment policy – Patient complaint procedure – Transfer of care to another provider – Consent forms (including treatment of minors) – Advance directives

Clarifies HR issues – Hiring - Application process, forms and reference checks

– Verification of credentials and identity

– Verification of Immunization and TB testing

– Compliance with employment laws

– Job descriptions

– Various employee policies • Employee grievance policy

• Workplace violence policy

• Disciplinary procedures

• Employee training

• Dress code

Policy Manual Section – Personnel

Policy Manual Section – Records

Describes policies and procedures for patient health records

– Mandated logs

– Records maintenance

– Records storage

– Archiving of hardcopy records

– Backup of electronic records

– Documentation of missed appointments and communication of all test results

Policy Manual Section – Infection Control

Describes policies and procedures to allow personnel to provide safe care and assess infection prevention practices – Hand hygiene

– Personnel protective equipment

– Injection safety

– Respiratory hygiene

– Environmental cleaning

– Sterilization of equipment

– Disinfection of reusable instruments

Policy Manual Section – Risk Management

Describe routine policies needed to cover

– Potential fraud

– Lapses in confidentiality

– Adverse patient outcomes

– Lawsuits

– Compliance plan and compliance officer as required by the OIG

Policy Manual Section – Quality Management

Describes the practice’s policies and procedures for quality control

– Assessment procedures

– Improvement plans

Summary

• Ambulatory care settings continue to

evolve and face many challenges in

patient safety and compliance with laws on

business practice.

• Risk management is essential to meet

these challenges.