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Clinical Risk

Clinical Risk

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Clinical Risk

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  1. Clinical Risk

  2. 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

  3. Liability Suit • Insurance company will cover unless it is criminal activity • Insurance cannot cover license status

  4. 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

  5. Major Issues in Clinical Risk Management • Have policies & procedures that are attainable • Have attainable standards of care

  6. Negligence • Elements necessary for liability • Duty to perform • Breach of duty • Personal injury or monetary damage • Proximate cause • Causal relationship breach of duty & damage

  7. 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

  8. 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

  9. 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

  10. What Physicians Dislike Most • Completing an incident report • Involve physicians in developing policy for handling complaints

  11. Types of Exposure When an Incident Occurs • Property • Income • Personnel • Liability

  12. Standard of Care • Prescribed mode of treatment according to an expectation

  13. Tort • An injury • Intentional Tort • Touching a person without consent • Unintentional Tort • Negligence created without intent, duty of care, breach, foreseeability, proximate cause, damage

  14. Golden Rule • How do you feel about what you have done

  15. Battery vs. Assault • Battery • Injuring person • Assault • Put someone in fear of injury

  16. Reasonably Prudent Person • What one would expect from a competent person

  17. Res Ipsa Loquitur • Defendant’s burden to prove he/she is not negligent

  18. Joint & Several Liability • Defendants can be sued together • They sort out who was responsible between them

  19. Impact Rules • Just scaring someone not enough to sue • Must actually impact the person & injure him/her

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. Development of Proactive Risk Management Program • Identifies areas of potential risk • Develop means of addressing risk exposures

  27. 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

  28. 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

  29. 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

  30. 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

  31. What Could Have Been Done to Prevent Litigation • 35% Apologize or offer further explanations • 25% “Correct the error” • 16% Wanted compensation

  32. Types of Damages • Compensatory • Non-Economic • Pain and suffering • Economic • Loss of income & inability to work • Punitive • Egregious offenses

  33. Credentialling

  34. Three Part Process • Credentialling • Privileging • Reappointment

  35. Content of Credentialling Packet • Establishes initial applicant qualifications • Signed application • Drug Enforcement Agency certificate • Certificate from medical specialty board • Certificate of insurance

  36. 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

  37. 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

  38. Privileges • Individually tailored scope of care granted • Provider qualifications • Provider competence • Support of medical staff

  39. 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

  40. Contents of Reappointment Packet • Specialized training certification(s) • Checking delinquency status of signed medical records • Disciplinary proceedings or sanctions by medical staff

  41. Governing Board Responsibilities • Policy maker • Delegates implementation & management • Retains responsibility for overall control • Fiduciary duty to patients to maintain, guard, & preserve quality of care

  42. Governing Board Responsibilities • Appoint qualified physicians • Have systems in place to verify credentials of physicians • Have systems in place to monitor work of practitioners

  43. 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

  44. HealthCare Quality Improvement Act of 1986

  45. Purposes • To address medical staff incompetence • To prevent incompetent physicians from relocating • To reduce malpractice claims

  46. Expectations • Increase in anti-trust litigations

  47. Prescription • Provide a safe harbor for physicians & others when participating in: • Credentialling • Issuing of clinical privileges • Peer review

  48. Three Results of HCQIA • Limited immunity • Reporting to NHPDB • Permissive access to information maintained by NHPDB

  49. 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

  50. Activities Protected • Professional activity involving: • Credentialling • Clinical privileges • Membership • Review of : • Competence • Professional conduct