Risk Management Handbook for Health Care Organizations

ROBERTA CARROLL, ARM, MBA, CPCU, CPHRM, is senior vice president of Aon Healthcare based in Tampa, Florida.

• Exhibits, Figures, Tables, and, Photos ixThe Contributors xiiiPreface xxviiAbout the Book xxixONE Development of a Risk Management Program 1Learning Objectives 1Risk Management Program Development 3Key Structural Elements of the Risk Management Program 4Scope of the Risk Management Program 8The Risk Management Process 13Evolution of the Risk Management Program 21Selecting an Appropriate Risk Management Program Structure 22Assessing Areas of the Organization That Need Risk Management 23Key Components for Getting Started 26Writing a Risk Management Program Plan 27Achieving Program Acceptance 27TWO The Health Care Risk Management Professional 31Learning Objectives 31The Risk Manager’s Job: Functional Areas of Responsibility 33Health Care Risk Management across a Spectrum of Settings 53Required Skills for the Successful Health Care Risk Management Professional 76Risk Management Ethics 77A Profile of the Health Care Risk Management Professional 78Education and Professional Recognition Programs 78THREE Patient Safety and the Risk Management Professional 87Learning Objectives 87The Scope of Medical Errors 89Seeking Solutions: What Are the Causes of Medical Errors? 91FOUR Health Care Legal Concepts 115Learning Objectives 115Legal Issues Common to All Health Care Providers 116Legal Issues Related to Specific Health Care Providers 134FIVE Governance of the Health Care Organization 157Learning Objectives 157Essential Responsibilities of the Hospital Board 159Basic Legal Duties of Health Care Trustees 160Lessons from the Panel on the Nonprofit Sector 162Federal Sentencing Guidelines for Organizations 165The Sarbanes-Oxley Act of 2002 167The Volunteer Protection Act of 1997 169Risk Management and the Board 170The Medical Staff, Risk Management, and the Board 175SIX Early Warning Systems for the Identification of Organizational Risks 181Learning Objectives 181Early Identification of Exposure to Loss 182Food and Drug Administration 206Institute for Safe Medication Practices, United StatesPharmacopeia, and National Coordinating Council for Medication Error Reporting and Prevention 208Medical Event Reporting System—Transfusion Medicine 212Intensive Care Unit Safety Reporting System 212Pittsburgh Regional Healthcare Initiative 212Other Voluntary Programs 212Standardizing a Patient Safety Taxonomy:The National Quality Forum 213Protecting Sensitive Information 213SEVEN the Risk Management Professional and Medication Safety 219Learning Objectives 219Latent and Active Failures 220Systems Thinking 221Risk Management: A Prioritizing Approach 252Eight Ethics in Patient Care 261Learning Objectives 261Ethical Principles and Moral Obligations 263Research 263Institutional Review Boards 266Patient Self-Determination Act 275“Do Not Resuscitate”: Withholding or Withdrawing Treatment 277NINE Documentation and The Medical Record 287Learning Objectives 287Documentation 291Record Retention 310Release of Records 310Ownership of Medical Records 311Medical Record Audits 312Documentation and Risk Management 313Emerging Risk Exposures 320The Risk Management Professional’s Role 321TEN Statutes, Standards, and Regulations 327Learning Objectives 327Patient Care 328Medicare Modernization Act 331Medical Staff 332Life Safety Code 350Federal Health Insurance Laws and Regulations 354Tort Reform 357Policy and Procedure Manuals 359Case Law 360ELEVEN Basic Claims Administration 367Learning Objectives 367The Claims Environment 368The Claims Process 369The Risk Management Professional’s Responsibilities 371Regulatory Reporting of Claims 378TWELVE Introduction to Risk Financing 381Learning Objectives 381Risk Financing in the Context of the Risk Management Process 384Risk Retention 384THIRTEEN Insurance: Basic Principles and Coverages 395Learning Objectives 395Definition of Insurance 396Specific Types of Insurance for the Health Care Industry 408FOURTEEN Information Technologies and Risk Management 427Learning Objectives 427Risk Management Information Needs 430Risk Management Information Systems 431Using Information Systems to Generate Reports 432Integrating Risk Management, Quality Assurance, and Patient Safety 433Electronic Mail 434Internet- and Web-Based Technology 435Personal Health Record 435Electronic Health Records and Systems 436Clinical Information Systems and “Smart” Technologies 437Infrastructure Technology 440Point-of-Care Technology 442Telemedicine 442Appendix 14.1: IT Glossary for Risk Managers 447FIFTEEN Risk Management Metrics 451Learning Objectives 451Benchmarking Defined 453Claims 456Measuring Change 459Developing New Metrics 461SIXTEEN Acreditation, Licensure, Certification, and Surveying Bodies 467Learning Objectives 467The Consumer Era of Health Care 468What the Health Care Risk Management Professional Needs to Know 469Mandatory Surveying Bodies 471Voluntary Surveying Bodies 475URAC 489Appendix 16.1: Accreditation and Licensure Organizations, Surveying Bodies, and Government Agencies 501SEVENTEEN Emergency Management 503Learning Objectives 503The Steps of Emergency Management 505Prevention 506Planning and Preparation 511Implementation and Response 525Recovery 526Recommended Web Sites 528EIGHTEEN Occupational Safety, Health, and Environmental Impairment 529Learning Objectives 529Administrative Procedure Act 530Administrative Enforcement 532Specific Occupational Safety and Health Issues 535APPENDIX A A RISK MANAGEMENT PROGRAM (EXAMPLE) 543APPENDIX B REQUEST FOR RECORDS form (EXAMPLE) 549APPENDIX C A GUIDE TO MEDICAL TERMINOLOGY 551GLOSSARY 565INDEX 623