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Clinical Risk. Clinical Risk Refers to People Who Provide Patient Care. Nursing services Physicians Support Staff Social Workers Dietary Pharmacy Lab Services Licensed and/or certified people. Liability Suit. Insurance company will cover unless it is criminal activity
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Clinical Risk Refers to People Who Provide Patient Care • Nursing services • Physicians • Support Staff • Social Workers • Dietary • Pharmacy • Lab Services • Licensed and/or certified people
Liability Suit • Insurance company will cover unless it is criminal activity • Insurance cannot cover license status
Major Issues in Clinical Risk Management • Must have qualified staff • Check licenses and certifications routinely • Non-proficient staff must work in tandem with qualified person • Universal precautions • i.e. gloves
Major Issues in Clinical Risk Management • Have policies & procedures that are attainable • Have attainable standards of care
Negligence • Elements necessary for liability • Duty to perform • Breach of duty • Personal injury or monetary damage • Proximate cause • Causal relationship breach of duty & damage
Incident Reporting Process • Peer reviewed • Report within 72 hours to Risk Manager • Process for review • Aggregate data to Risk Management Committee • Data to Governing Board
How to Gain Physician Support • Demonstrate benefits • Personalize the benefits • Decreases insurance costs • Develop personal relationships with leading physicians who have power in the organization • Stress educational benefits • Develop training around topics of interest to physicians
How to Gain Physician Support • Develop physician handbook • System for identifying & reporting potential losses or injuries • What physicians should do with summons or complaints • Informed consent • What to do if called by a lawyer • Legal requirements for reporting certain types of incidents
What Physicians Dislike Most • Completing an incident report • Involve physicians in developing policy for handling complaints
Types of Exposure When an Incident Occurs • Property • Income • Personnel • Liability
Standard of Care • Prescribed mode of treatment according to an expectation
Tort • An injury • Intentional Tort • Touching a person without consent • Unintentional Tort • Negligence created without intent, duty of care, breach, foreseeability, proximate cause, damage
Golden Rule • How do you feel about what you have done
Battery vs. Assault • Battery • Injuring person • Assault • Put someone in fear of injury
Reasonably Prudent Person • What one would expect from a competent person
Res Ipsa Loquitur • Defendant’s burden to prove he/she is not negligent
Joint & Several Liability • Defendants can be sued together • They sort out who was responsible between them
Impact Rules • Just scaring someone not enough to sue • Must actually impact the person & injure him/her
General Issues of Clinical Risk • Assessment Exposures • Failure to include all elements of an assessment • Bottom line = documentation • Personal & family history • Medications • Allergies • Chief complaints • Physical assessment • Mental & emotional status • Lifestyle habits
General Issues of Clinical Risk • Assessment Exposures • Failure to secure above information will increase exposure to liability • Do assessment ASAP • Answer all questions on form • Focus questions on chief complaint • Always return to patients to validate incomplete information • Observe patients with adequate frequency
General Issues of Clinical Risk • Assessment Exposures • Failure to communicate • Must recognize certain information must go to the physician • Certain information should trigger an immediate intervention • If physician is unavailable, contact immediate supervisor
General Issues of Clinical Risk • Planning Exposures • No or low data • Perform thorough assessment • Failure to note patient problems • Demonstrate your knowledge about patient • Non-specificity of data • Do not use vague terms
General Issues of Clinical Risk • Planning Exposures • Failure to encourage shift continuity • Document carefully & directly in the patient chart • Poor discharge instructions • Good written discharge instructions regarding after-care • Allow time to ask questions • Note in chart that patient verbalized an understanding
General Issues of Clinical Risk • Intervention/Treatment Exposures • Misreading orders • Patient identity mistakes • Errors in patient positioning • Medication errors • Hospitals = 1/7 prescriptions • Surgery = 1/12 prescriptions • Inappropriate use of restraints • Improper patient instructions
Development of Proactive Risk Management Program • Identifies areas of potential risk • Develop means of addressing risk exposures
Elements of Proactive Risk Management Program • Identification of high risk exposure in clinical departments • Identification of key staff who can assist in recognition of behaviors leading to injuries or their potential • Identification of types of clinical incidences which always result in departmental or interdisciplinary reviews
Elements of Proactive Risk Management Program • Coordinate with hospital departments in order to create change • Focus on the process of delivering quality care rather than patient injury
Motives of Malpractice Plaintiffs • 40% Felt humiliated by their experience with their physician • 50+% Felt betrayed by their physician • 80+% Felt embittered by physician’s responses to their complaints & questions
Motives of Malpractice Plaintiffs • 90+% Were very angry at their physicians • 24% Felt physicians were dishonest and misled them • 20% Felt “court was the only way to find out what happened” • 19% Wanted to punish the doctors
What Could Have Been Done to Prevent Litigation • 35% Apologize or offer further explanations • 25% “Correct the error” • 16% Wanted compensation
Types of Damages • Compensatory • Non-Economic • Pain and suffering • Economic • Loss of income & inability to work • Punitive • Egregious offenses
Three Part Process • Credentialling • Privileging • Reappointment
Content of Credentialling Packet • Establishes initial applicant qualifications • Signed application • Drug Enforcement Agency certificate • Certificate from medical specialty board • Certificate of insurance
Content of Credentialling Packet • Current license • Other state license(s) • Pre-medical college degree • Medical school diploma • Certified copy of exchange certificate for foreign medical graduates
Content of Credentialling Packet • Detailed explanations for “yes” answers to specific questions • Names of three references with completed reference forms • Evidence of F/U calls to references • National Health Practitioner Data Bank (NHPDB) inquiry
Privileges • Individually tailored scope of care granted • Provider qualifications • Provider competence • Support of medical staff
Contents of Reappointment Packet • Recredentialling & reprivileging • Signed & dated attestation • DBPR & NHPDB inquiry results • Insurance company information regarding litigation • Updated copies of license(s) • Continuing Education course credits
Contents of Reappointment Packet • Specialized training certification(s) • Checking delinquency status of signed medical records • Disciplinary proceedings or sanctions by medical staff
Governing Board Responsibilities • Policy maker • Delegates implementation & management • Retains responsibility for overall control • Fiduciary duty to patients to maintain, guard, & preserve quality of care
Governing Board Responsibilities • Appoint qualified physicians • Have systems in place to verify credentials of physicians • Have systems in place to monitor work of practitioners
Peer Review Duties of Medical Staff • Authority delegated & granted by governing board • Bylaws, rules, & regulations are an instrument of delegation • Peer review then becomes an instrument for action against a colleague • Legitimate peer review is protected by privilege, statute, & public policy
Purposes • To address medical staff incompetence • To prevent incompetent physicians from relocating • To reduce malpractice claims
Expectations • Increase in anti-trust litigations
Prescription • Provide a safe harbor for physicians & others when participating in: • Credentialling • Issuing of clinical privileges • Peer review
Three Results of HCQIA • Limited immunity • Reporting to NHPDB • Permissive access to information maintained by NHPDB
Who Has Immunity • Those serving on professional review bodies • Those assisting review body • Those serving as witnesses on behalf of review body • Those under contract to review body • Those serving on staff review bodies
Activities Protected • Professional activity involving: • Credentialling • Clinical privileges • Membership • Review of : • Competence • Professional conduct
